Covid/cold/flu Patient TCM Diagnosis Form

Basic Information

*Legal Name |全名

Preferred Name

*Gender

Male

Female

*Date of Birth |生日

*Height(cm) |身高

*Weight(kg) |体重

Body Temp(C) |体温

Days of Fever |发热天数If you are in fever

Upload Zone |上载区

Please use the rear camera to take pictures with your tongue out naturally under natural light. |请使用后置摄像头，在自然光之下，自然伸出舌头病进行拍照。

*Tongue surface picture

*Under tongue picture

Face picture (optional, but important)

Whole body picture (optional, but important)

Other picture 1 (if any, such as rash, ulcer)

Other picture 2 (if any, such as rash, ulcer)

Files Upload (if any, such as medical reports) |文件上传（如有，医学报告等）

* Why we need thoese information? Your age, height and weight help us determine the dosage of the herbal medicine. Your face, tongue and body shape picture are vital for TCM diagnosis.

I understand by signing and submitting this form that the information provided is true to the best of my knowledge. I will advise this clinic of any changes to the above details during future visits.

I have read, fully understood and agreed with the patient consent, service rules, term and conditions, and the privacy.

*Signature

Designed by HS Chinese Medicine Clinic. Copyright by HSCM

Warning: this note contains the personal information subject to privacy protection, unauthorized reading is prohibited.

Covid/cold/flu Patient TCM Diagnosis Form

Please fill in carefully. It is very important for us to fully understand your current situation. 请务必认真填写。让医生全面了解你的现状，对治疗是非常重要的。

Designed by HS Chinese Medicine Clinic. Copyright by HSCMWarning: this note contains the personal information subject to privacy protection, unauthorized reading is prohibited.

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Designed by HS Chinese Medicine Clinic. Copyright by HSCM

Warning: this note contains the personal information subject to privacy protection, unauthorized reading is prohibited.