TCM Music Therapy Intake Form

Patient Information

Full name
Gender
Age
Country
Address
Email
Phone number
Other contact
Body temperature
Heart rate (bpm)
Blood pressure
Duration of illness
Main complaint / symptoms

Cold & Heat Patterns

Fear of cold / chills
Fear of wind
Fear of heat
Alternating fever & chills
Interior heat & exterior cold

Sweating

Sweating present
Location of sweating

Head & Face

Headache
Dizziness / vertigo
Stiff neck & back
Dry nose
Nasal congestion
Runny nose
Nasal discharge (clear/turbid)
Sore under nose

Mouth & Throat

Bitter taste in mouth
Bad breath
Toothache
Sore throat
Dry throat
Foreign object sensation

Thirst & Hydration

Thirsty / dry mouth
Prefer cold or hot water
Daily water intake

Digestive & Nausea

Dry heave / retching
Vomiting
Acid regurgitation
Stomach distention / bloating
Vomit after eating
Hunger but no appetite

Cough & Respiration

Coughing
Cough with phlegm
Phlegm nature (clear/turbid)
Persistent asthma / wheezing

Ears & Hearing

Ear blockage
Deafness
Tinnitus

Body & Musculoskeletal

Skin sores / rashes
Body pain (general)
Lower back pain
Bone / joint pain
Restless / agitation
Yellowish skin
Abdominal fullness / heaviness
Facial / mouth numbness
Any body ache

Chest & Cardio

Irritable / vexation
Palpitations
Chest fullness
Rebellious qi / rising sensation
Chest oppression / anxiety
Shortness of breath
Lack of qi (fatigue)
Epigastric hardness
Chest pain
Substernal pain
Hard lump under chest
Painful or whip-like pain
Epigastric fullness without pain
Nausea / queasy
Heartburn / feverish chest

Ribs & Hypochondrium

Rib pain
Hypochondriac hardness
Water qi sensation

Abdomen & Bowel

Abdominal pain
Abdominal mass
Palpitation below navel
Lower abdominal urgency
Rumbling abdomen

Back & Spine

Back pain
Back aversion to cold

Limbs & Extremities

Cold hands & feet
Difficulty stretching limbs
Leg cramps
Heavy / painful limbs

Urinary Patterns

Difficulty urinating
Frequent urination
Urinary urgency
Involuntary urination
Urine color
Urine volume

Stool Pattern

Constipation
Diarrhea
Incomplete evacuation
Sticky stool
Mucus / blood in stool

Sleep Quality

Insomnia / difficulty falling asleep
Easily awakened
Drowsiness / hypersomnia

Mental & Emotional

Confusion / incoherence
Feverish talk / delirium
Weary & drowsy
Irritability / easy anger

Medical Background

Past medical history
Known cause of illness

Menstrual & Gynecology (Female)

Menstrual regularity
Menstrual blood color
Blood clots
Dysmenorrhea
Other menstrual discomforts
Vaginal discharge
Discharge color
Discharge amount (heavy/scanty)
Vaginal odor
Breast distension / tenderness

Tongue & Facial Diagnosis

Tongue color
Facial complexion (normal)
Reddish face
Pale face
Bluish face
Dark / blackish face

Pulse Characteristics

Floating pulse
Tight pulse
Strong / forceful (Hong)
Deep pulse
Slippery pulse
Fine & weak pulse

Daily Routine & Habits

Bedtime (sleep time)
Wake-up time
Daily work / occupation

Additional Information

Other instructions
Remarks
Music therapy
Exercise therapy
TCM herbal therapy
Art therapy
Tea therapy