Fields with an asterix " * " must be completed.

 

*Real Name:
*Email
*Street Address:
*City, State, Zip Code:
*Age:
*Gender:	Male	Female
Telephone:
Fax:

PRESENT ILLNESS

*What is your chief complaint?

When did this condition begin? 

What treatment, if any, have you already received?

Tell us what you would like from this online consultation:
I want to receive herbal medicine to treat my condition if possible. (CLICK HERE TO GO DIRECTLY TO THE HERBAL STORE AND GET YOUR FREE GIFT)
I just want to know if acupuncture can treat my condition, but I am not ready to do anything about it.
Other. Describe in the space below:

IF YOU HAVE CHECKED THE HERBAL STORE AND ARE STILL NOT SURE WHAT HERBS ARE BEST FOR YOUR CONDITION, ANSWER THE REST OF THE QUESTIONNAIRE BELOW, OTHERWISE CLICK

*ONLY FILL IN THE REST OF THE QUESTIONAIRE IF YOU ARE PLANNING TO PURCHASE HERBAL MEDICINE!*

PAST MEDICAL HISTORY

Please indicate whether you have or had any of the following conditions by checking all that apply:

1. HIV virus
2. Herpes simplex
3. Epstein Barr virus
4. Heart disease or heart attack
5. Rheumatic fever
6. High blood pressure
7. Stroke
8. Epilepsy or convulsions
9. Kidney or bladder problems
10. Diabetes
11. Tumor or cancer
12. Respiratory disease
13. Pneumonia or emphysema
14. Tuberculosis
15. Asthma
16. Hepatitis
17. Peptic ulcer or pancreatitis
18. Anemia or other blood disorder
19. Bleeding disorders
20. Jaundice
21. Hernia
22. Hemorrhoids
23. Thyroid disorder
24. Venereal disease
25. Genital or gynecological disorders
26. Congenital abnormalities
27. Skin disease
28. Do you have a pacemaker?
29. Do you have any surgical implants?
30. Have you had a change in bowel or bladder habits?
31. Do you have any sores that will not heal?
32. Do you have any unusual bleeding or discharge?
33. Do you have indigestion or difficulty swallowing?
34. Have you noticed an obvious change in a wart or mole?
35. Do you have a nagging cough or hoarseness?
36. Do you smoke?
37. Do you drink?

Fractures and other serious injuries:

Allergies:

Please list any medication taken, the dose, and how often you take it:

FAMILY HISTORY

Has any blood relative had any of the following:

1. Stroke
2. Cancer
3. Heart disease
4. Tuberculosis
5. Bleeding Tendency
6. Diabetes
7. High blood pressure

PRESENT SIGNS AND SYMPTOMS

1. Chest pains
2. Palpitations
3. Difficulty falling asleep
4. Restless sleep
5. Nightmares
6. Night sweating
7. Heat sensations in hands and feet
8. Unusual or excess sweating

 
9. Cough
10. Skin problems
11. Difficulty breathing
12. Sore throat
13. Stiff neck
14. Depression
15. Pale face
16. Nasal problems
17. Asthma
18. Intolerance to weather changes
19. Fever and/or chills
20. Loss of voice
21. Red eyes
22. Eye problems
23. Sinus problems
24. Phlegm

 
25. Stomach pain
26. Gas
27. Belching
28. Heartburn
29. Nausea
30. Vomiting
31. Mouth sores
32. Diarrhea
33. Loose stool
34. Constipation
35. Hemorrhoids
36. Bruise easily
37. Lack of appetite
38. Excessive appetite
39. Easily tired
40. Cravings
41. Thirst
42. Desire of cold drinks
43. Desire of hot drinks
44. Bloating after meals

 
45. Excessive worry
46. Bitter taste in mouth
47. Easily irritable or angry
48. Headaches
49. Twitching or spasms of muscles
50. Facial redness
51. Brittle nails
52. Pain in the rib area
53. Hernia

 
54. Cold limbs
55. Edema (water retention)
56. Ear ringing
57. Deafness
58. Back pain
59. Knee pain
60. Easily frightened
61. Urinary problems
62. Night urination
63. Decreased sexual drive
64. Poor memory
65. Joint pain
66. Hair loss
67. Dizziness

 
68. Discharge between periods
69. Menstrual cramps
70. Excessive menstrual bleeding
71. Clots
72. Breast swelling or pain
73. Irregular menstruation
74. Pregnant

 
75. Premature ejaculation
76. Impotence