问诊单
Patient Intake Forms

如有以下问题可详细说明，以便医生能知晓病情，合理用药。
（The following questions can be explained in detail, so that doctors can understand the condition and use medication reasonably.）
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1.
姓名
Name
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2.
性别
Sex
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3.
年龄
Age
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4.
身高
Height
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5.
体重
Weight
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6.
主要有什么不舒服?
What's the main discomfort?
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7.
饮食偏好
Food preferences
【最少选择1项】
寒凉（冷饮、雪糕等）（Cold Drinks）
甜食（Sugary foods）
水果（Fruits）
牛奶（Milk）
辛辣（Spicy）
饮酒（Drink alcohol）
无特殊偏好（Have no special preference.）
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8.
白天容易犯困吗?
Do you feel sleepy during the day?
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9.
头重脚轻吗?
Top-heavy?
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10.
身体沉重吗?
Is the body heavy?
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11.
眼睛有没有不舒服?（比如眼睛干涩发痒、眼屎多、视力下降）
Are your eyes uncomfortable? (For example, dry and itchy eyes, excessive eye discharge, decreased vision)
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12.
早上口苦吗?
Is it bitter in the morning?
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13.
嗓子干不干?
Is your throat dry?
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14.
肋骨下方一圈有没有压痛点?
Is there any tenderness in the circle below the rib?
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15.
平时容易口渴吗?（如果口渴的话喝水能解渴吗，喜欢热水还是冷水?）
Are you usually thirsty? (If you are thirsty, can drinking water quench your thirst? Do you prefer hot water or cold water?)
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16.
怕不怕风吹?
Afraid of the wind?
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17.
怕冷还是怕热?
Is it cold or hot?
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18.
平时容易出汗吗?
Do you sweat easily?
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19.
小腿有没有鱼鳞状皮肤、掉白皮屑?
Does the calf have fish-scaled skin or white scales?
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20.
大便多久一次、干还是稀、臭不臭、有没有未消化食物?拉完会不会感觉没排干净?
How often do you have a bowel movement, dry or thin, smelly, and whether there is any undigested food? Does it feel like it's not clean?
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21.
小便费不费劲、颜色如何、一天几次?有没有泡沫?浑浊吗?
Is it easy to urinate, what is the color, how many times a day? Is there any foam? Is it cloudy?
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22.
睡眠怎么样?梦多吗?容易醒吗?
How about your sleep? Do you dream a lot? Is it easy to wake up?
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23.
容易受到惊吓吗?
Are you easily scared?
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24.
容易烦躁吗?
Are you upset?
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25.
食欲和饭量怎么样，有没有恶心呕吐?
How is your appetite ? Are you feeling nauseous or vomiting?
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26.
有没有口腔溃疡?容易长口腔溃疡吗？
Do you have oral ulcers?
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27.
每天会不会固定时间发热?
Do you have a fixed time of fever every day?
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28.
黄昏会发热或觉得特别累或困吗?
Do you feel hot or tired or sleepy at dusk?
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29.
有没有皮肤病?皮肤会发黄吗？
Do you have any skin diseases?Dose the skin turn yellow？
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30.
睡觉流口水吗?（有没有梦游、磨牙、盗汗、鬼压床等）
Do you drool when you sleep? (Are there any sleepwalking, teeth grinding, night sweats, etc.)
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31.
冬天手脚温度如何?
手指和脚趾温度会不会比手脚其它位置更凉?
What is the temperature of the hands and feet in winter?
Are your fingers and toes colder than the rest of your hands and feet?
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32.
症状在白天和夜晚会不会加重或减轻?
Are symptoms different during the day and at night?
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33.
后背有没有巴掌大一块发凉，或者整个后背发凉?
Does the back feel cold in a palm-sized area, or the entire back?
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34.
是否一直吃什么都不胖?会脱发吗?
Do you always eat anything without getting fat? Will it lose hair?
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35.
腹部侧面有没有胀痛?
Is there any bloating pain on the side of the abdomen?
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36.
有没有胸闷气短心悸?如有请详细描述。
Do you have chest tightness, shortness of breath, palpitations?
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37.
胳膊肘痛不痛?
Does the elbow hurt?
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38.
胃会胀吗?
Will you have stomach bloating?
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39.
脸发黑吗?
Does your face turn black?
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40.
嘴唇干燥吗、有没有干裂或起皮?
Are the lips dry, cracked, or peeled?
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41.
身上有没有哪里疼痛或麻木？
Is there any pain or numbness in your body?
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42.
坐着到站起有没有头晕?
Do you feel dizzy from sitting to standing up?
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43.
有没有偏头痛史?
Any history of migraines?
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44.
平时容不容易叹气?
Do you usually sigh easily?
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45.
平时喜欢操心吗？是不是控制欲特别强？
Do you like to worry about things?Are you particularly controlling?
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46.
晒太阳、泡热水澡有没有不舒服？
Does sunbathing or taking a hot bath make you uncomfortable?
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47.
饿的时候容不容易头晕眼花、烧心、浑身无力，吃了东西就能缓解？
When you're hungry ,do you easily fell dizzy ,have heartburn ,fell weak all over ,and relieved after eating? 
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48.
冬天有没有冻疮
Is there frostbite in winter?
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