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健康资产预审表 Pre-Audit Form

表单说明 / Introduction：

感谢您预约线上健康决策评估。为了在接下来的 30 分钟视频对谈中直接进入深度的病机拆解，请您如实填写这份“身体账本”。本表单的底层逻辑基于传统中医最严苛的生理健康十大标准，您的每一项反馈，都是我判断您阴阳运转与气血盈亏的核心依据。数据严格保密。

Thank you for scheduling your Online Health Decision Assessment. To ensure our 30-minute video consultation is fully dedicated to deep clinical analysis, please complete this "body balance sheet." The logic of this form is based on the rigorous Ten Golden Standards of TCM Physiology. Your data is strictly confidential.

第一部分：基础档案与核心负债 | Part 1: Basics & Core Liabilities

您的姓名 | Your Name

年龄与性别 | Age & Gender

WhatsApp No（用于接收会议链接与最终报告）

(For meeting links & final report delivery

第二部分：核心负债 | Part 2: Current Liabilities

主诉（核心困扰） | Primary Concern (The Core Liability)

请用一句话描述您目前最急需解决的健康问题。（例如：持续半年的凌晨3点早醒、长期的餐后腹胀等） Please describe the most pressing health issue you need to resolve right now in one sentence. (e.g., Waking up at 3 AM for the past 6 months, chronic bloating after meals) [段落 / Paragraph]

病程时间 | Duration

这个困扰持续了多久？ How long have you been experiencing this issue?

动态变量 | Dynamic Variables (Aggravating & Alleviating Factors)

在什么情况下症状会加重或缓解？（如：熬夜后加重、热敷后缓解） Under what circumstances do your symptoms worsen or improve? (e.g., worsens after late nights, improves with a hot compress) [段落 / Paragraph]

第三部分：既往损耗 | Part 3: Historical Depletion

既往确诊记录 | Past Medical Diagnosis

过去是否曾被明确诊断过任何慢性疾病？（若无，请填“无”） Have you ever been diagnosed with any chronic diseases? (If none, please write "None")

外伤与手术史 | Surgical & Trauma History

是否经历过全麻手术、脏器摘除或重大外伤？ Have you undergone any surgeries under general anesthesia, organ removal, or major physical trauma?

长期用药清单 | Current Medications & Supplements

目前是否在规律服用任何处方药或保健品？ Are you currently taking any prescription medications or supplements regularly?

第四部分：日常现金流审计 | Part 4: Daily Physiology Audit

能量补给（饮食与消化） | Energy Intake (Appetite & Digestion)

(单选题 / Single choice)

能量补给（饮食与消化） | Energy Intake (Appetite & Digestion)

正常，吃饭觉得香，饭后不胀 | Normal, food tastes good, no bloating after meals

胃口差，吃得很少，不知饥饿 | Poor appetite, rarely feel hungry

容易饿，但吃一点就胀气 / 必须吃重口味 | Hungry easily but bloat quickly / Crave heavy flavors

食欲亢进，总觉得吃不饱 | Excessive appetite, never feel full

水液运化（口渴与饮水偏好） | Hydration (Thirst & Temperature Preference)

(单选题 / Single choice)

水液运化（口渴与饮水偏好） | Hydration (Thirst & Temperature Preference)

正常口渴，饮水量适中，喜欢常温或温水 | Normal thirst, prefer room-temp or warm water

很少口渴，一整天都不想喝水 | Rarely thirsty, no desire to drink water all day

极度口渴，喝水后仍觉口干（多饮） | Extreme thirst, still feel dry after drinking

口渴但不想咽下，或极度渴望喝冰水 | Thirsty but don't want to swallow, or crave ice-cold water

代谢清算（大便状态） | Metabolic Clearance (Bowel Movements)

(单选题 / Single choice)

代谢清算（大便状态） | Metabolic Clearance (Bowel Movements)

每日一次（早晨最佳），成型且顺畅 | Once daily (ideally morning), well-formed & smooth

几天一次，干燥难排（便秘） | Once every few days, dry & difficult to pass

容易腹泻，大便不成形 / 夹杂未消化食物 | Prone to diarrhea, unformed / contains undigested food

粘马桶，感觉排不干净 | Sticky, feeling of incomplete evacuation

代谢清算（小便状态） | Metabolic Clearance (Urination)

(单选题 / Single choice)

代谢清算（小便状态） | Metabolic Clearance (Urination)

尿频，颜色极淡（如清水），夜尿频繁 | Frequent, very pale (like water), frequent night urination

尿液深黄、少量，伴有灼热感 | Dark yellow, small amount, burning sensation

每天 5-7 次，淡黄色，量足 | 5-7 times daily, pale yellow, adequate volume

系统休眠（睡眠质量） | System Hibernation (Sleep Quality)

(单选题 / Single choice)

系统休眠（睡眠质量） | System Hibernation (Sleep Quality)

沾枕即睡，一觉到天亮，醒后精神饱满 | Fall asleep instantly, sleep through the night, wake up energized

入睡困难（躺下超过 30 分钟无法入睡） | Difficulty falling asleep (>30 mins)

浅眠易醒，整夜多梦 | Light sleeper, frequent dreams

凌晨特定时间（如 1-3 点或 3-5 点）必然醒来 | Wake up at a specific early hour consistently (e.g., 1-3 AM)

营卫枢纽（出汗与心胸感觉） | Defensive Qi (Sweating & Chest Sensations)

(多选题 / Multiple choice)

营卫枢纽（出汗与心胸感觉） | Defensive Qi (Sweating & Chest Sensations)

阴阳温控（体表温度分布） | Yin-Yang Thermal Distribution (Body Temp)

(单选题 / Single choice)

阴阳温控（体表温度分布） | Yin-Yang Thermal Distribution (Body Temp)

额头凉爽，手脚常年保持温暖 | Cool forehead, hands and feet are always warm

常年手脚冰凉（特别是冬天或冷气房内） | Chronically cold hands and feet

上热下寒（容易长痘/口腔溃疡，但手脚冰凉） | Heat in upper body (acne/mouth ulcers) but cold feet

手心、脚心经常发热，甚至想贴在冷处 | Palms and soles feel hot, desire to touch cold surfaces

第三部分：性别专属健康资产 | Part 3: Gender-Specific Assets

(中医认为男精女血，此部分是评估肝肾核心资产的关键指标。请根据您的性别填写对应问题，另一题留空即可。) (This section evaluates core Kidney/Liver assets. Please answer the question corresponding to your gender and leave the other blank.)

【女性专属】经期状态 | [Female Only] Menstrual Status [对应倪师标准：正常的月经]

您的月经周期是否规律（约28天）？经期是否在 3-5 天左右？是否有严重的痛经、暗红色血块或经前乳房胀痛？ Is your cycle regular (approx. 28 days) and lasts 3-5 days? Do you experience severe cramps, dark blood clots, or PMS breast tenderness?

【男性专属】晨间阳气指标 | [Male Only] Morning Yang Vitality [对应倪师标准：正常的早晨勃起]

您是否有规律的晨勃？（这是评估男性肾阳与精气储备最重要的指标） Do you experience regular morning erections? (This is the primary indicator of Kidney Yang and essence reserves.) (单选题 / Single choice)

【男性专属】晨间阳气指标 | [Male Only] Morning Yang Vitality [对应倪师标准：正常的早晨勃起]

每天都有，非常规律 | Daily, very regular

偶尔有，频率降低 | Occasional, decreased frequency

几乎没有 | Rarely or never

请拍摄高清舌象，前后｜Pls Upload tongue image front and back

Size limit: 10 MB

您的健康资产数据已加密提交。请您在预约时间准时进入会议室。您的每一份反馈，都将在接下来的 30 分钟里，被转化为最严谨的医学逻辑。期待与您的深度对话。

Your health asset data has been securely submitted. Please join the meeting room on time. Every detail you provided will be translated into rigorous medical logic during our 30-minute consultation. I look forward to our deep-dive dialogue.