Your Full Name  
Sex  
Date of Birth  
Phone  
Email  
Height  
Weight  
Race  
Marital Status  
Number of Childern  
Occupation  
Describe your symptoms in details
When did you have the symptom(s)?  
Have you visited a practitioner for the problem?   
What was the diagnosis and what was the treatment ?  
Have you seen a herbalist or acupuncturist?  
What Chinese herbs have you taken before?  
How long have you taken it and What benefits did you get from ?  
Please select "Yes" or "No" to the following questions.Please give more details if you select "Yes"
Diabetes
Anemia
Depression
Headaches
Allergies
Hypoglycemia
Sinus Infections
Heart Disease
Angina
Palpitation
Angina
Spasms
High Cholesterol
High Blood Pressure
Low Blood Pressure
Stroke
Hepatitis
TB
Enlarged Liver
Shortness of Breath
Cancer
Hearing Difficulties
Kidney Problems
Cold Limbs
Fever
Heat Intolerance
Cold Back
Fatigue
Lassitude
Weak Voice
Night Sweat
Pale Face
Flushed Face
Weak Pulse
Short Breath
Dizziness
Ear Ringing
Blurred Vision
Red Eye
Hair Loss
Grey Hair
Asthma
Cough
Cough with Phlegm
Frequent Colds & Flu
Running Nose
Stuffy Nose
Sore throat
Chewing Difficulties
Dry Mouth
Bitter Mouth
Poor Memory
Emotional Stress
Anxiety
Insomnia
Frequent Daytime Urination
Frequent Nighttime Urination
Color of Urine
Urine Difficulties
Diarrhea
Constipation
Bloating
Weight Gain
Weight Loss
Poor appetite
Nausea
Vomiting
Indigestion
Heartburn
Stomachache
Change in bowl habits
Dry stool
Loose stool
Irregular Bowel Movements
Any Pain (Neck,Shoulder,Back,etc)
Normal Energy Level
Normal Sex Drive
Frequent Smoker
Alcohol Addiction
Drug Addiction
Unhealthy General Diet
Frequent Eat-Outs
Little Physical Exercises
For Men Only
Low Sex Drive
Impotence
Weak Erection
Premature Ejaculation
Emission
Masturbation
For Women Only
Pregnancy
Irregular Menstruation
Pain Menstruation
Bleeding between periods
Hot Flash
Previous Abnormal Delivery
Additional information on your health conditions that have not been indicated above:

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             Chinese Medicine Consultation
In-Depth Health Evaluation from the Perspective of Traditional
Chinese Medicine (TCM)
for a minimal fee by a licensed acupuncturist professionally trained in TCM.

Here is how it works.
1. Fill in and submit the evaluation form below.
2. Pay $40 consultation fee.
3. Our licensed TCM doctor will evaluate your health.
4. We will notify you within 1-5 days the evaluation result and recommend
any herbal remedy as needed.
5. You may purchase the remedies from us or other sources at your
discretion.

For the most accurate evaluation, please complete the form below carefully
and thoroughly. Your privacy will be strictly protected
.
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