感冒和急证问诊单 中英版（感冒久治不愈的请用杂病问诊单）
(INQUIRY FORM FOR COLD OR FLU (for long lasting cold or flu, please use GENERAL DIAGNOSIS FORM)
** “口”为选择项（可多重选择）请打勾或可采用不同颜色表示；“ ”为填写项。
”Multiple choices, please check the box or highlight the selections, multiple selections permitted “ ” To be filled out.
族裔Ethnicity ；(*for possible hints regarding diet habits, climate acclimation, and family health history。。。)
1、寒热 Chill / Fever or Heat Sensation
口恶寒 aversion to cold 口 发热 fever or heat sensation 口恶风 aversion to wind
口恶寒发热同时并见 concurrent “aversion to cold” and “fever / heat sensation" ---
a. 口 恶寒重 more "aversion to cold" than "fever or heat sensation"
b. 口 发热重 more "fever or heat sensation" than "aversion to cold"
口发热恶寒每日有定时 / 寒热往来 alternating “aversion to cold” and “fever/heat sensation"---
a. 几时发热更高 what times per day of "fever or heat sensation" higher ？
b. 几时更恶寒 what times per day of "aversion to cold" stronger ？
c. 一日恶寒/发热几次 how many times per day of aversion to cold/fever or heat sensation ？
2、汗 Sweat
口 额头皮肤干燥 forehead skin dry 口 脸上有油感 face oily 口 脸上无油感 face not oily
口 有汗 sweat/perspiration 口 无汗 no sweat / perspiration 口 大汗淋漓 excessive sweating
口 珠汗粘身 sticky beads of sweat / （thick）oily sweat that sticks to the body
口 一直高热无汗 high fever without sweat
汗出部位 which part of the body is sweaty ？
汗出时间规律 time pattern of sweat/perspiration？
3、口渴 Thirst
口 嘴皮干裂起皮屑 chapped lips with peeling skin 口 嘴皮有竖纹 vertical lines on lips
口 唇色鲜红 lip color bright red 口 唇色暗红 lip color dark red
口 渴欲饮水 thirsty , desire to drink water 口 大渴大饮 very thirsty desire to drink more water 口 渴但不欲饮水thirsty without desire to drink 口 喜冷饮 prefer cold drink 口 喜热饮 prefer hot drink 口 喝热汤舒服 feel better after having hot soup 口 怕喝热汤 feel worse after having hot soup or avoid hot soup
口 便后不久又有便意 returning to defecate again soon after finishing 口 肛门热灼 hot / burning sensation on anus 口 肛门寒凉 cold sensation on anus 口 便秘 constipation 口 臭味比平时重 Foul-smelling stool more than usual 口 大便失禁 fecal incontinence
b, 吐出物的形态 vomitus form---
口纯液体Liquid 口含未消化的食物semi solid due to undigested food
比较液体与含消化的食物哪种较多 estimated ratio between the liquid part and the solid(undigested food)
？
口味 taste in mouth----
口 有甜味 sweet 口 有苦味 bitter 口 有酸味 sour 口 有辣味 hot and spicy
口 有咸味 salty 口 容易饿 hungry so often 口 食欲好食量大 excessive hunger than usual
7、咳嗽 Cough / 咽Throat
口 不咳 no cough 口 带痰 cough with phlegm 口 干咳 dry cough 口 咳运动后加重 coughing more after physical exercise 口 遇冷加重 coughing more in cold 口 遇热加重coughing more in heat
何时咳较重 At what time of day your cough is worse---
口 早晨 morning 口 午后 afternoon 口 黄昏 late afternoon/dusk 口 夜卧 night time lying down 口 半夜 23-1点 23pm-1am 口 凌晨4-5点 4am-5am 口 咽痛 sore throat 口 咽肿swollen throat 口 声哑 hoarseness
8、痰 Phlegm / 鼻涕 Snot/Nasal Mucus，眼屎 Eye Discharge A、 痰 Phlegm
口 有痰 with phlegm 口 无痰 no / without phlegm 口 痰鸣 gurgling with phlegm 口 痰粘sticky phlegm 口 痰黄 yellow phlegm 口 水样痰 watery phlegm 口痰易咳出 easy to cough up
口 痰不易咳出 difficult to cough up 口 痰吞下 / 咳出不会马上再有痰 (no immediate recurring of phlegm after it being cleared )
B、鼻涕 Snot/Nasal Mucus
口 鼻塞 snuffle nose 口 一个鼻孔堵塞 single-sided stuffy nose 口 两个鼻孔交替堵塞 alternating stuffy nose 口 睡时塞 stuffy while asleep 口 醒时塞 stuffy while awake 口 持续塞 constant stuffy 口 黄涕 yellow mucus 口 粘稠涕 thick mucus 口水涕 watery mucus 口 鼻干燥 dry nose 口 鼻屎干结 dried mucus 口 鼻内有干血块 dried blood clots in the nose
A、 痛的部位 which part of the body is in pain/the location of the pain---
口 头痛 headache （头痛的位置headache location？）
口 前额 forehead 口 眼窝 eye sockets 口 眉骨 eyebrows 口 脸颊 cheeks 口 头后 back of the head 口 头顶 top of the head 口 颈部 neck 口 耳后 behind the ears 口耳前 in front of the ears
B、痛的性质the quality/type of the pain ---
口 胀痛 distending / bloating 口 刺痛 stabbing 口 头如裹 heavy headed as if wet towel tightly on head
口 钝痛 dull 口 持续痛 persistent pain
10、舌Tongue / 舌苔Coating of the Tongue 口腔Oral A、 舌质 tongue conditions ---
口舌干 dry / no saliva 口 舌湿 moistened/wet 口 舌底发干 dry below tongue 口 舌疮 sores
B、舌色 unusual tongue color ---
口 红 red 口淡粉 light pink 口 深 红 dark red 口 紫 dark Purple/Bruising 口 黑black 口白 white / pale
C、舌苔Coating of the Tongue ---
口 无苔 no coating at all 口 苔厚 thick 口 苔薄 thin 口 苔白 white 口苔黄yellow 口 黏腻苔 sticky greasy 口 湿苔 slippery 口 焦干parched 口 黑 black 口积粉苔 powder-like 口 有芒刺 prickly 口象草莓 strawberry-like
D、门牙 front teeth ---
口 有光泽 shiny 口 干燥无光泽 incisors dry and dull 口 干枯 dried-up
E, 牙龈 gums---
口 牙龈色红 bright red gums 口 牙龈色淡 lighter color than usual/slight pink gums 口 牙龈红肿痛 red swollen gums 口 牙龈溃疡 gums sores
11、不适症状轻重程度发作规律 Symptoms’ time pattern ，when feeling worse？
口 白天重夜里轻 during daytime 口 白天轻夜里重 at night 口 晨起重 morning 口 傍晚重 early evening 口 午后重 afternoon
病程多久了 How long have you experienced these symptoms
？
哪种症状有何规律，请详细注明 Are there any patterns to your symptoms? Please provide details
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发表于 2014-5-22 09:59:29
楼主
发表于 2014-5-22 10:08:58
发表于 2014-5-22 10:23:06
谢谢，谢谢！
发表于 2014-5-22 21:10:37
太好了，可以学学英文！
放上了， 试试看？
