问诊单\nPatient 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.）
1. 姓名
Name
2. 性别
Sex
3. 年龄
Age
4. 身高
Height
5. 体重
Weight
6. 主要有什么不舒服?
What's the main discomfort?
7. 饮食偏好
Food preferences
8. 白天容易犯困吗?
Do you feel sleepy during the day?
9. 头重脚轻吗?
Top-heavy?
10. 身体沉重吗?
Is the body heavy?
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)
12. 早上口苦吗?
Is it bitter in the morning?
13. 嗓子干不干?
Is your throat dry?
14. 肋骨下方一圈有没有压痛点?
Is there any tenderness in the circle below the rib?
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?)
16. 怕不怕风吹?
Afraid of the wind?
17. 怕冷还是怕热?
Is it cold or hot?
18. 平时容易出汗吗?
Do you sweat easily?
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?
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?
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?
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?
23. 容易受到惊吓吗?
Are you easily scared?
24. 容易烦躁吗?
Are you upset?
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?
26. 有没有口腔溃疡?容易长口腔溃疡吗？
Do you have oral ulcers?
27. 每天会不会固定时间发热?
Do you have a fixed time of fever every day?
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?
29. 有没有皮肤病?皮肤会发黄吗？
Do you have any skin diseases?Dose the skin turn yellow？
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.)
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?
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?
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?
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?
35. 腹部侧面有没有胀痛?
Is there any bloating pain on the side of the abdomen?
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?
37. 胳膊肘痛不痛?
Does the elbow hurt?
38. 胃会胀吗?
Will you have stomach bloating?
39. 脸发黑吗?
Does your face turn black?
40. 嘴唇干燥吗、有没有干裂或起皮?
Are the lips dry, cracked, or peeled?
41. 身上有没有哪里疼痛或麻木？
Is there any pain or numbness in your body?
42. 坐着到站起有没有头晕?
Do you feel dizzy from sitting to standing up?
43. 有没有偏头痛史?
Any history of migraines?
44. 平时容不容易叹气?
Do you usually sigh easily?
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?
46. 晒太阳、泡热水澡有没有不舒服？
Does sunbathing or taking a hot bath make you uncomfortable?
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? 
48. 冬天有没有冻疮
Is there frostbite in winter?
更多问卷 复制此问卷