TCM Body Shaping — Patient Assessment | Aatmshakti Institute of Integrated Medical Research

👤

SECTION 1

Patient Identity

Date *

Form No. (clinic use)

Referred By

Full Name *

Age *

Date of Birth

Gender *

Mobile / WhatsApp *

Email

City / State *

Occupation

⚖️

SECTION 2

Anthropometrics & Body Measurements

Weight (kg) *

Height *

BMI (auto)

—

Enter weight & height

⚖️

Target Weight (kg)

Duration of Weight Issue

Previous Lowest Weight (kg)

Body Measurements (cm)

Body Area	Current (cm)	Target (cm)	Notes
Waist / Belly
Hips
Thighs (R / L)
Upper Arms (R / L)
Chest / Bust
Neck

Major Weight Area

Abdominal Type (Yichen)

🎈 Balloon 🌿 Liver Qi (upper) 🧊 Cold Damp (lower) 🌊 Kidney Deficiency

👅

SECTION 3

TCM Tongue Diagnosis

🧬

SECTION 4

TCM Constitution Type (Yichen System)

🌬️

Qi Deficiency

Fatigue, SOB, pale, spontaneous sweating

🧊

Yang Deficiency

Cold limbs, loose stools, low libido, oedema

💧

Phlegm-Damp

Greasy coat, heaviness, mucus, foggy mind

🔥

Damp-Heat

Oily skin, acne, bitter taste, turbid urine

🌑

Blood Stasis

Dark complexion, fixed pain, dark circles

🌀

Qi Stagnation

Emotional, chest tightness, mood swings

⚖️

Balanced

Good energy, even mood, regular digestion

Secondary / Mixed Constitution

📋

SECTION 5

Chief Complaint & Weight History

Main Concern *

Age at Onset of Weight Gain

Triggering Event

Rate of Weight Gain

Fluctuating Weight?

Associated Symptoms

❓

SECTION 6

TCM Ten Questions — Shi Wen (十問)

Question	Options (tick all that apply)	Notes
1. Thirst & Fluids	Thirsty (prefers cold) Thirsty (prefers warm) Dry mouth, little thirst Not thirsty Oedema/water retention
2. Appetite & Digestion	Good appetite Poor appetite Ravenous/constant hunger Sweet cravings Bloating after eating Nausea
3. Sleep	Sound sleep Hard to fall asleep Wakes frequently Excessive sleep Disturbing dreams Insomnia
4. Bowel Movement	Regular (1-2×/day) Constipation Loose/watery Alternating Undigested food Sticky/difficult
5. Urine	Normal (pale yellow) Frequent/pale Scanty/dark Nocturia Foamy Burning
6. Perspiration	Normal No sweating Profuse sweating Night sweats Spontaneous daytime
7. Temperature	Feels cold overall Cold hands/feet Feels hot overall Hot palms/soles Alternating hot-cold
8. Pain / Discomfort	No pain Headaches Joint pain Abdominal pain Back pain Chest tightness
9. Energy & Emotions	Good energy Fatigue/tiredness Depression/sadness Anxiety/worry Irritability/anger Brain fog
10. Chest & Abdomen	Clear Chest tightness Epigastric distension Abdominal fullness Palpitations Shortness of breath

🌸

SECTION 7

Menstrual & Gynaecological History

Complete for female patients only.

Menopausal Status

Pre-menopausal Peri-menopausal Post-menopausal N/A

Cycle Length (days)

Menses Duration (days)

Last Menstrual Period (LMP)

Flow & Colour

Gynaecological Conditions

Pregnancies / Live Births

Trying to Conceive?

🏥

SECTION 8

Medical History & Comorbidities

Diagnosed Medical Conditions

Current Medications / Supplements

Known Allergies

Previous Surgeries

Treating Physician (if any)

Lab Values (if available)

Test	Value	Normal Range
Blood Sugar (FBS / HbA1c)		FBS 70–100 / HbA1c <5.7%
Thyroid (TSH / T3 / T4)		TSH 0.4–4 mIU/L
Cholesterol (LDL / HDL)		LDL <100 / HDL >40
Vitamin D3		30–100 ng/mL
Haemoglobin / Iron		F: 12–16 / M: 13.5–17.5

🍃

SECTION 9

Lifestyle & Habits

Smoking

Alcohol

None Occasional Social/weekend Regular/daily

Diet Type

Eating Pattern

3 regular meals Frequent snacking Skips meals Late-night eating Stress eating

Physical Activity

Sedentary Light (walks) Moderate (3–4×/wk) Active (5+×/wk)

Water Intake

Sleep Duration (hours)

Sleep Quality

Energy Level (1=exhausted, 10=vibrant)

Stress Level (1=calm, 10=extreme)

Motivation for Change (1=low, 10=very high)

🔄

SECTION 10

Previous Attempts & Goals

Methods Previously Tried

Best Result Achieved

Reason for Regain / Failure

Primary Goal

Timeline Expected

Additional Notes

I confirm that the information provided is accurate and complete. I consent to the TCM Body Shaping assessment and treatment procedures as recommended by Dr. Amit Kapoor.

Patient Name (for consent)

Consent Date

🌿 TCM Body Shaping Programme

Patient Assessment & Clinical Intake Form