Medical record filling method: 1. Medical record prompts are asked questions as a need for consultation, which helps Chinese medicine doctors and patients to communicate authentically and error-free online, and jointly build a fortress of Chinese medicine diagnosis in the disease. This is the characteristics of the network consultation. 2.After filling in one article according to the prompt, delete the prompt to form a normal narrative paragraph, and then fill in the next article. 3.After filling in one article, check whether there are errors in sentences, paragraphs and punctuation marks. Form a complete and true disease record. It can be sent to any TCM group and any TCM doctor for consultation. Avoid unnecessary misunderstandings and mistakes. The information of the visit is a very serious thing, and is one of the important factors in determining the Chinese disease. Never be careless, the patient must be responsible for himself first! 4.Obtaining tongue information picture information is crucial. You can use a digital camcorder or computer camera to take pictures yourself, enter them into the computer database and then pass them to the doctor for processing. If you do not have the equipment, you can have the doctor take the video on site during the visit. In this case, the patient extends the whole tongue to the strong light and the camera head, set the position, and let the doctor click “screenshot” to take a clear picture according to the procedure. At least three pictures of the tongue are needed: the front full tongue (you can see the root of the tongue), the side full tongue, and the bottom of the tongue. 5.Some of the conditions really do not allow, fill out the can not, so we have to forget. Medical history form: 1. Please fill in the following entries in detail: Name (real name): Gender: Male/Female Age: ? Year of birth: 19? month? Date? Occupation: ? Marriage: Yes? Not yet? Height: ? cm Weight: kg Skin color: Black? Yellow? Body shape: Thin Fat Onset: Year Month Origin: Province? County? Township: Current address (specific to city, county): Any bad habits (smoking, drinking, masturbation, staying up late, etc.): Complaint: Describe the main painful symptoms you feel and when they occurred. (As the main reference for treatment, please fill in the details): Characteristics of the main symptoms (which conditions can make the symptoms worse or less severe? (Related concomitant symptoms): Present history: describe in detail the time, season, place, cause, evolution of the disease, the nature and extent of the main symptoms and related concurrent evidence, the process of diagnosis and treatment and the effect of response: Past history: briefly describe what major diseases you have suffered from in the past, the time and treatment medication (variety, reflecting some information related to the disease): Other history: include personal and family circumstances: 2. Symptoms of the following body parts (copy the symptoms after the colon, please indicate separately if you have different symptoms, and fill in none/normal if you do not): Fever (high, medium, low fever: hot flashes. Fever (high, medium, or low fever: hot flashes, fever at regular intervals, fever in one area, fever all over the body): facial color (is it different from usual?) (red, yellow, white, black, blue, shiny or not?) Eye color: (red, swollen, painful, white eye color: blue, yellow, is there any blood? Are there any petechiae? Are there any dark spots? Is there any dryness, dizziness, tearing, swelling? Under-eye color, —- left, right): Tongue image, tongue color: (red, light red, light white, dark red, purple-red, blue, purple, is there any petechiae ecchymosis? Where? (red at the tip of the tongue, red at the edge of the tongue?) Tongue body: (thin, fat, with or without teeth marks on the edge of the tongue, is the tongue dry? (moist, moderate): Tongue coating: (thick, thin, yellow, white, black, greasy, putrid, or with or without coating? Or is it cracked? or is it glossy like a mirror? (Is there any peeling?) : pulse (just write it directly according to the medical record book, laymen can also choose slightly according to the following.) : *left: (fast, slow, strong, weak, coarse, fine, floating, sinking, late, counting, loose, tight, is there a pause? (sometimes fast, sometimes slow?) : *Right: (fast, slow, strong, weak, coarse, fine, floating, sinking, late, counting, loose, tight, with or without pause? (fast and slow?) Head (pain, dizziness, swelling, numbness, wood, faintness, heaviness, at the top of the head, both temples, back of the occiput, forehead, whole head): Neck (stiffness, pain, soreness, heaviness, swelling, area? When is it worse? Waking up from sleep? (active work?) Eyes (dryness, dizziness, vertigo, lacrimation, left, right): Ears (tinnitus, deafness, itching, pain, left, right): Nose (incompetence, runny nose, left orifice, right orifice, whole orifice, thick and thin nose, color, presence of nasal polyps, deviated septum, rhinitis, (paranasal) sinusitis): Mouth (dry mouth, thirsty or not? Bitter mouth? Greasy mouth? Sweet mouth? Tasteless? Is there any acidity? Is there any bad taste? Ulcers? Swelling and pain? (Is there drooling while sleeping?) Lips (red, light red, dark red, light white, pale, black, dry, cracked, sores): vomiting (yes, no, vomiting when eating, vomiting in the morning, vomiting in the evening, vomiting in the morning when eating in the evening, vomiting as undigested food? (acid, dry vomiting without vomiting): throat (dry, painful, itchy, difficulty swallowing, sensation of foreign body): chest (full, stuffy, distended, painful, hot, cool): breast (distended, painful, enlarged, lump, left, right): flank (distended, painful, hot, cool, left, right): heart (irritable, palpitating, panic, tight, painful, cool, hot, fast beating): subcardiac (full, blocked, distended, burning, painful): stomach (distended, painful, full, acidic, cool, hot, nature of pain, when does it get worse? When is it worse? (before and after meals?) Abdomen (swelling, distension, pain, fullness, hardness, coolness, heat, pressure, refusal to press, coldness, heat, bulging, varicose veins in the abdomen, intestinal sounds): Shoulder (pain, clotting, soreness, numbness, distension, coolness, heat, location? (left, right): Arms (pain, cool, hot, sore, numb, site? (left, right): hands (cool, hot, dry, sweaty, numb, shaky, parts? (left, right): back (pain, soreness, heaviness, numbness, swelling, coolness, heat, part? (left, right): waist (sore, heavy, painful, numb, cool, hot, swollen, part? (left, right, upper, lower, middle): vulva (swollen, swollen, painful, hot, cold, burning, swelling, contracture): legs (painful, sore, heavy, numb, woody, swollen, swollen, cool, hot, stiff, soft, part? (left, right): knee (pain, swelling, swelling, soreness, numbness, coolness, heat, softness, bone pain, left, right): foot (pain, numbness, swelling, coolness, heat, left, right): heel (pain, coolness, heat, numbness, swelling, left, right): toe (numbness, pain, swelling, coolness, heat, part? (left, right): 3. Please select the physical condition corresponding to the following items: Drink (more, less, like cool, like hot, like warm, like sour, like spicy, like bitter, like salty, like sweet): Food (more, less, like cool, like hot, like sour, like spicy, like bitter, like salty, like sweet, like rice, like noodles, like porridge, like greasy, like greasy): Sleep (more, less, usually easy to sleepy? Is it insomnia? Dreamy? Insomnia is not easy to fall asleep? Or wake up easily after sleep? Do you wake up from time to time? (Is it easy or difficult to fall asleep after waking up?) (frequency, dry, wet, sticky, greasy, constipation, incontinence, color, loose diarrhea, whether it is formed? Is there any burning in the anus when relieving? Is there any indigestible food? Are there any worm eggs? Is there any pus or blood? (Does it feel like you always want to have a bowel movement, but it doesn’t come out well?) (frequency, quantity, irregularity, incontinence, color, frequency, blood in urine? Is it cloudy? Is there any burning sensation? Is there any pain when urinating? Is there any pain when urinating? (Is there any abnormal odor?) Skin condition (rash, color of rash? Skin color? Is there any swelling, lump? Texture, sore, local color, itching? Pain? (Skin temperature?) : ★ For women, the following items are also added: Menstruation (cycle?) (more, less, early, delayed, dark red, dull, bright red, light red, thick, thin, with or without clots, amenorrhea): Leukorrhea (with, without, more, less, white, yellow, fishy, smelly): Fetal delivery (have you experienced any fetal delivery? How many pregnancies and births? Any history of miscarriage?) Pregnancy? Birth? (enlarged lymph nodes, sternal tingling, tiredness on standing, varicose veins, bone hollowing, bone fever, dream loss, premature ejaculation, impotence, infertility): 5. What are the seven emotions: melancholy (joy, anger, depression, thought, sadness, fear, palpitation): 6. Blood count, urine and stool, liver and kidney function, x-ray, ultrasound, endoscopy, CT, MRI, etc.: 7. Please send a photo of the patient’s lesion, face and tongue. Note: Please respect the labor of TCM doctors. Each prescription is a combination of the hard work and valuable time of the TCM doctor. Remind those who do not believe in TCM not to seek prescriptions from TCM practitioners. Due to the special nature of internet diagnosis, it is difficult to do a comprehensive four-way diagnosis, so please consider carefully whether you really agree with the medication. Once you use the medicine, you agree to use the medicine, and you will be responsible for all the consequences arising from it. In order to be responsible for yourself, please make sure to give feedback in time so that the treatment plan and prescription can be revised. If the patient does not fill out the medical record, the Chinese doctor takes the time and effort to look at it and may not get it right. If the patient does not fill out the medical record, the herbalist will have to spend time and effort to look at it, but will not be able to make any changes. Then the patient can’t be seen. Even if you can barely look at it, you will be prone to deviations. This is a sample of the patient’s medical record after completion. Maple floating: 18:19:09 Name (real name): so-and-so . Sex: Male Age: 24 years old Born: October 10, 1986 Occupation: Computer Marriage: Not Married Height: 1.7 cm Weight: 135 kg Place of origin: Shantou, Guangdong Province Current address: Guangdong-Foshan Onset: 2007 Major symptoms: prostatitis, scrotal cyst, varicocele. Detailed symptoms: painful urination, yellow urine, bifurcation of urine, fatigue, weakness, face sometimes easily baked, sweating, dry mouth, thirst, damp scrotum, fever, sweating, shortness of breath, irritability, easy to fear, weakness and tiredness, little breath and laziness, sleepiness, dreaming, impotence, premature ejaculation, heartburn. Stomach distension and stomach pain. Sometimes I feel that the palms of my hands are hot, sometimes I feel better when I take Zhi Bai Di Huang Wan and Jin Kui Kidney Qi Wan, but I feel better and worse, I have taken some western medicine, but the effect is not good, I get stomach problems, my eyes are dry and watery, I feel some swelling and swelling in my eyes, sometimes I tend to flow some tear-like things, sometimes I feel good soreness, my tongue is light red, my pulse: 80 beats per minute Neck pain, soreness, sitting for a long time is more likely to be sore. Sometimes I feel that my throat is not comfortable, my voice is small, my speech is not clear, my chest is stuffy and full, my sides are swollen and painful, and sometimes I feel upset. Heartbeat is fast. Easily full after meals, not so fast digested, sometimes painful, sometimes with intestinal sounds, easily sore in the back, vulvar swelling, easy to wake up at noon with numb hands and feet. Drinking less, preferring warmth, somewhat averse to oil. Poor sleep quality, easily sleepy in general. Dreamy, sometimes constipated. Sometimes I have to get up once at 2 or 3 pm to urinate, but not much. Sometimes I feel some heat, yellow urine and painful urination. I am depressed. I have had CT tests and other tests that are normal.