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South Baylo Univ.
Qin  aus
http://www.carbotrading.com
acumedic.com
Subject
ID Sex Male Female
Age Marital Status Married Single
Pulse / minutes Blood Pressure / mmHg
Children Occupation
Email
Consultation Please explain onset, symptoms and progress of your complaints.
Family History
Past Illness
Allergy
Voice Strong Medium Weak Alcohol (Cups/Day)
Physique Normal Obese Lean Cigarette (Packs/Day)
Appetite Good Regular Poor Height / Weight ft.   lbs.
Sighing Yes No Digestion Good Normal Poor
Phlegm Much Little None Phlegm Color Yellow White
Vomiting/Nauseation Yes No Stool times / day
Urine Frequent Normal  Bed-wetting Urine Color Normal White Yellow Red Opaque
Other :
Sweat Night-time sweating
Day-time sweating None
Lumbago Yes No
Insomnia Yes No Thirst Yes No
Hands/Feet Warm Cold Normal Fever Yes No
Headache Yes No Dizziness Yes No
Menstrual Pain Yes No Menstrual cycle days
Menstrual Period days Menstrual flow amount Heavy Normal Light
 Menstrual flow color Red Coffee 
Scarlet Lump
Date of last period
Menstrual discharge Large Normal Scanty
None
Discharge odor Yes No
 Discharge color Yellow White Discharge texture Normal Thin Thick
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