Korean Medical Clinic

Questionnaire for medical diagnosis

Questionnaire for medical diagnosis

LEE BYEONG SAM-Kyunghee Korean Medical Clinic is providing customers, who are unable to visit our clinic swiftly,

with approximate provisional dietary treatments by email, based on their physical constitution and the nature of disease,

which comprehended by our on-line brief diagnosis.

However, someone with unclear physical inclination must come to our clinic to get a clear prescription,

in terms of his physical constitution not sharply reflected in the questionnaire.

Please click the button which you feel most suitable to you.

When completed, Don't forget to click 'POST' button at the bottom of this page.

Each single person of your family must log in separately when taking questionnaire.

Name
Date of
birth
year month date
Sex
Height
cm
Weight
kg
E-Mail
Phone
Overall
Tendency
Personality
When angry
When making a
self-assertion
When expressing
one's opinion
When working
Personal relations
(positve)
Personal relations
(negative)
Normally
On new things
When angry
When working
In one's childhood

From the following list, mark the food items that you like or have a digestion problem.

Foods I have a
digestion
problem
with it.
I like it
very much.
Foods I have a
digestion
problem
with it.
I like it
very much.
Foods I have a
digestion
problem
with it.
I like it
very much.
apple clam barley
grapes raw fish glutinous rice
peach pork sesame seed oil
chestnut chicken ginseng
persimmon lamb honey
banana beef orange juice
melon goat meat sweet potato
cucumber chives potato
watermelon lettuce deer antlers
pear oyster milk
strawberry crab flour
cold noodle shrimp coffee
mackerel red bean green tea
chocolate

· Please list all foods or medicine that you've had any problems with it. And describe the symptoms or syndrome.

Fill in the blank or mark the ones that apply to you.

  • My hands are ( )
    My feet are ( )
  • I can't tolerate ( )    /   ( )
  • During sleep, ( )
  • I drink ( ) water
  • I prefer ( ) food
  • I eat ( )
  • ( )
  • I suffer from ( ) and I have a bowel movement times in days.
  • When I'm suffering from constipation ( )
  • My urine ( )
  • I sweat (  /  )
  • I do exercise for hours a day on average.
  • I sleep hours a day. I sleep ( )
  • ( )
  • My body parts that currently hurt the most are (
    )
  • Major symptoms

03. Please list all disorders from your family and relatives who are now suffering or have suffered in the past.

04. Please list all major disorders which you have suffered in the past.

05. Please list all medicine (including a painkiller) you have taken in the past or are currently taking.
You may write down its name or its ingredient.

06. Please describe your current symptoms briefly.

07. For females only.

  • I have a ( ) menstrual cycle, and my menstrual cycle is betw days and days.
    The length of my menstrual cycle is days. I have (

    )

  • I have the most amount of menstruation on the [1st, 2nd, 3rd] day of menstruation.
    I had my first menstrual period at the age of .
    The total number of pad I use during my period is Thin , Regular , Overnig , Maximum protection
  • If there are blood clots, each clot is about (
    )
  • My menstrual fluid is /    (
    )
  • My symptoms include ( )    /    ( )
  • From the age of , I take (name of the painkille) tablets or capsules a day when in period.