慧吃师兄ai中医健康问卷

您好!感谢您选择慧吃师兄ai中医健康服务。为了更准确地了解您的健康状况,为您提供更具针对性的调理建议,请您认真阅读在仔细填写以下问卷。所有信息将严格保密,请放心填写。
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姓名
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性别
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年龄
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婚育史(如:已婚已育,有无剖腹产等)
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职业
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身份证号
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确诊病名(如有)
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确诊医院(如有)
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快递收件地址/电话/联系人
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D1 既往病史与治疗经过(曾经得过的重大病和受过的伤都要说,女性请说明生育史、有无剖腹产等)
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D2 饮食习惯与生活习惯(如:特别喜欢烧烤/煎炸食物、抽烟喝酒、作息紊乱、容易生气等)
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D3 起病时间与诱因(何时起病?有无特殊情况,如感冒后、吃某食物后、情绪波动后、受打击后等)
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D4 目前体力与精神状态(能否自如行走?能否生活自理?总体精力如何?)
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D5 口部感觉(是否有口干、口苦、口淡?)
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D6 主要不适与伴随症状(⚠️ 很重要!请认真填写目前最不舒服的地方及伴随症状)
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D7 饮食情况(饭量如何?食欲好坏?有无偏食、厌食?)
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D8 二便情况(大便次数/性状?小便颜色/频次?)
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D9 睡眠休息(入睡难易?睡眠质量?有无失眠多梦?)
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D10 畏寒怕风(有无畏寒?怕风?手脚是否发凉?)
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D11 发热与潮热盗汗(有无发热/潮热/盗汗?手心脚心是否发热?让家人摸手脚与腹部温度是否不同?)
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D12 补充说明(以上未尽事宜,请在此补充任何您认为重要的信息)
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填表人
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填表日期
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