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Consultorio Tao yin

Csar Ramrez T.
Medicina tradicional China
www.medicinachinayogaperu.com

CUESTIONARIO MTCH
Nombre completo del paciente ___________________________________________________

Fecha de nac.

Hora de nac.

Peso

Altura cm..

Lugar

Estado civil.

Comente y detalle sus SINTOMAS


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Cuntas horas duerme? ____

Hora de levantarse_______

Hora de acostarse_________

Hora de tomar desayuno y de almorzar_____________________________________________

Detalle los alimentos que suele


comer________________________________________________________________________
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Cules de estas emociones le predomina ms - subraye dos


Tristeza - alegra - preocupacin miedo - clera - otra

Cules son sus actividades en la maana ?


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Cules son sus actividades en la tarde?


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Cules son sus actividades en la noche?
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Cules de estos sabores prefiere, subraye dos
cido,

dulce,

amargo, salado,

Duerme bien, suea mucho?

picante

Hace siesta por las tardes?

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Mencione sus comidas y bebidas


preferidas_____________________________________________________________

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Vicios o manas
detectadas.___________________________________________________________________
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Frmacos que toma y a que


horas________________________________________________________________________
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Algo que desee


agregar_______________________________________________________________________
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