方天亮线上中医咨询表

只需要几分钟就能填好，可勾选多个项目，别忘了发送舌头上下面的照片和脸部照片。

方天亮健康服务 | FANG TIANLIANG HEALTH SERVICES

线上中医咨询ONLINE TCM CONSULTATION

极简初诊表 | Quick First Consultation Form

约 3–5 分钟。只填写与本次咨询有关的资料；医师会根据需要再追问。About 3–5 minutes. Provide only information relevant to this consultation; the practitioner may ask follow-up questions.

紧急情况请拨打 999；需要尽快处理但非紧急的问题，请联系 NHS 111 或您的 GP。 / For emergencies call 999. For urgent non-emergency concerns, contact NHS 111 or your GP.

1. 基本资料 | BASIC INFORMATION

项目 / Field	请填写 / Your Answer
姓名 / Full Name	____________________________
出生年月 / Month & Year of Birth	____________
生理性别 / Sex at Birth	☐ Female 女  ☐ Male 男  ☐ Prefer not to say
电子邮箱 / Email	____________________________
首选语言 / Preferred Language	☐ 中文  ☐ English  ☐ Other: ______
联系电话（可选） / Telephone — Optional	____________________________

2. 这次主要想咨询什么？ | WHAT WOULD YOU LIKE HELP WITH?

可多选；不知道疾病名称也没关系，可直接选择症状。 / Select all that apply. If you do not know the diagnosis, select your symptoms.

心血管与代谢 | Cardiovascular & Metabolic

☐ 高血压 High blood pressure   ☐ 高血脂/高胆固醇 High cholesterol   ☐ 糖尿病/血糖高 Diabetes/high blood sugar☐ 心慌/心律不齐 Palpitations/irregular heartbeat   ☐ 胸闷 Chest tightness   ☐ 其他心血管问题 Other cardiovascular

呼吸、感冒、鼻与过敏 | Respiratory, Colds, Nose & Allergy

☐ 反复感冒/感冒久不愈 Frequent colds/prolonged cold symptoms   ☐ 咳嗽 Cough   ☐ 哮喘 Asthma☐ 慢性支气管/COPD Chronic bronchial/COPD   ☐ 鼻炎/鼻窦问题 Rhinitis/sinus problem   ☐ 花粉症/过敏 Hay fever/allergy

消化与排泄 | Digestion & Bowel/Urinary

☐ 胃痛/消化不良 Stomach pain/indigestion   ☐ 胃酸倒流/烧心 Reflux/heartburn   ☐ 腹胀 Bloating☐ 便秘 Constipation   ☐ 腹泻/大便稀 Diarrhoea/loose stools   ☐ IBS/肠易激 IBS   ☐ 排尿问题 Urinary problem

疼痛、关节与神经 | Pain, Joints & Neurological Symptoms

☐ 颈肩痛 Neck/shoulder pain   ☐ 腰背痛 Back/lower-back pain   ☐ 关节炎/关节痛 Arthritis/joint pain☐ 头痛/偏头痛 Headache/migraine   ☐ 头晕 Dizziness   ☐ 麻木/神经痛 Numbness/nerve pain   ☐ 耳鸣 Tinnitus

睡眠、精力与情绪 | Sleep, Energy & Emotional Wellbeing

☐ 失眠/睡眠不好 Insomnia/poor sleep   ☐ 疲劳/乏力 Fatigue/low energy   ☐ 压力/焦虑 Stress/anxiety   ☐ 情绪低落 Low mood

其他常见问题 | Other Common Concerns

☐ 甲状腺问题 Thyroid problem   ☐ 慢性肾脏问题 Chronic kidney problem   ☐ 皮肤问题 Skin problem☐ 湿疹/瘙痒 Eczema/itching   ☐ 水肿 Swelling/oedema   ☐ 体重问题 Weight concern

女性/男性健康 | Women's & Men's Health

☐ 月经问题 Menstrual problem   ☐ 更年期 Menopause   ☐ 备孕/生育问题 Fertility concern☐ 前列腺/排尿问题 Prostate/urinary problem   ☐ 性功能问题 Sexual health concern

☐ 其他 Other: ______________________________________________________________

项目 / Field	请填写 / Your Answer
最主要的问题 / Main concern	____________________________
什么时候开始？ / When did it begin?	____________________________
困扰程度 / How much does it bother you?	0 1 2 3 4 5 6 7 8 9 10
最希望改善什么？ / What would you most like to improve?	____________________________

3. 身体整体情况 | OVERALL BODY PATTERN

寒热 Temperature: ☐ 怕冷 Cold ☐ 怕热 Hot ☐ 冷热交替 Alternating ☐ 无明显偏好 Neither

出汗 Sweating: ☐ 正常 Normal ☐ 易出汗 Easy ☐ 很少出汗 Little ☐ 夜汗 Night sweats

睡眠 Sleep: ☐ 好 Good ☐ 入睡困难 Hard to fall asleep ☐ 易醒 Wakes often ☐ 早醒 Wakes early

胃口 Appetite: ☐ 正常 Normal ☐ 较差 Poor ☐ 容易饿 Often hungry

饭后 Digestion: ☐ 正常 Normal ☐ 腹胀 Bloating ☐ 反酸 Reflux ☐ 恶心 Nausea

大便 Stool: ☐ 正常 Normal ☐ 干硬 Hard ☐ 稀溏 Loose ☐ 黏滞 Sticky

口渴/饮水 Thirst: ☐ 正常 Normal ☐ 经常口渴 Thirsty ☐ 很少口渴 Rarely thirsty ☐ 喜冷饮 Prefer cold ☐ 喜热饮 Prefer warm

精力 Energy: 0 1 2 3 4 5 6 7 8 9 10 （0 很差/very low；10 很好/very good）

4. 重要医疗资料 | IMPORTANT MEDICAL INFORMATION

项目 / Field	请填写 / Your Answer
已有诊断 / Existing diagnosis	与本次问题有关的医生诊断（如有）：Relevant diagnosis, if any: ____________________
目前用药 / Current medicines	重要处方药、中药或中成药：Important prescription medicines, Chinese herbs or patent products:____________________
过敏 / Allergies	☐ 无 None  ☐ 有 Yes：药物/食物及反应 / Drug/food and reaction: __________
重要病史 / Important medical history	重要疾病、手术或住院经历（如有）：Major illness, surgery or hospital treatment, if any: __________

请勿因线上建议自行停止或改变 GP 开具的药物。 / Do not stop or change prescribed medicines without consulting your GP.

5. 照片和报告 | PHOTOS & REPORTS

建议上传 / Recommended

☐ 舌头正面照片（舌面） / Upper Surface of Tongue自然伸出舌头，拍清整个舌面；自然光、无滤镜。 / Extend the tongue naturally; show the whole upper surface; natural light, no filter.

☐ 舌头底部照片（舌下） / Under the Tongue轻轻抬起或卷起舌头，拍清舌下部位；不要过度用力。 / Gently lift or curl the tongue; show the underside clearly; do not strain.

如适用 / If applicable

☐ 症状部位照片 / Photo of affected area☐ 检查报告 / Relevant medical reports☐ 面部正面照片（可选） / Front facial photo — optional

6. 还有什么需要告诉医师？（可选） | ANYTHING ELSE? — OPTIONAL

________________________________________________________________________________________________________________________________________________________

7. 同意并提交 | CONSENT AND SUBMISSION

本服务用于非紧急线上中医咨询。线上建议不能完全代替面对面检查；请勿因线上建议自行停止或改变 GP 开具的药物。您提交的资料用于咨询和病历管理，仅供获授权、负责您咨询的人员查看；未经另行同意，不用于广告或公开案例。This service is for non-emergency online TCM consultation. Online guidance cannot fully replace an in-person examination. Do not stop or change prescribed medicines without consulting your GP. Submitted information is used for consultation and record-keeping, accessed only by authorised personnel responsible for your consultation, and will not be used for advertising or public case studies without separate consent.

☐ 我已阅读以上说明，确认资料属于本人并尽我所知准确，我同意提交。I have read the above, confirm the information is mine and accurate to the best of my knowledge, and agree to submit.

姓名 / Name: __________________________   日期 / Date: 系统自动记录 / Recorded automatically

未满18岁 / Under 18: 由家长或法定监护人完成同意 / Consent must be completed by a parent or legal guardian.