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The reason why you have to fill out this form seriously is that TCM is totally different than western medicine, and it emphasizes every exact individual symptom very much. Even for the same disease, there are many different reasons to cause it from person to person. Therefore the treatment is also different from person to person. Thanks for your understanding and cooperation.
Note: The following blanket with * must be filled.

*Name: *Address:
*Email: *City:
*Gender: malefemale *Country:
Marriage Status: Postal code:
*age: *phone:
Height:Meters Skype:
Weight:Kgs MSN:
Do you have children?: Occupation:
*Disease history: how many years:
Application Time:
*What about your major complaints at present? Do you have the health problems of the heart and blood pressure? Serious or slight?
Detailed Symptoms About You
1. Head, Eyes, Nose, Ears, Mouth
  • headache
  • great loss of hair
  • slight loss of hair
  • hair loss with oily scalp
  • blurred vision
  • blood-shot eyes
  • dizziness
  • tinnitus with noise of chirping of a cicada
  • reduced hearing ability
  • pale complexion
  • swollen and painful nose
  • runny nose
  • thin and white nasal discharge
  • thick and yellowish discharge
  • blockaded sense in the nose
2. Mouth & Tongue
  • a bitter taste in the mouth
  • sour taste in the mouth
  • dry lips
  • slightly reddish tongue body
  • slightly whitish tongue body
  • deep-red tongue body
  • fissured tongue body
  • tooth-marks on the edges of the tongue
  • I brush the tongue coating daily
  • thick tongue coating
  • thin tongue coating
  • thin and white tongue coating
  • thick and white tongue coating
  • thin and yellow tongue coating
  • thick and yellowish tongue coating
3. Throat & Neck
  • stiff neck
  • painful neck
  • itching throat
  • dry throat
  • swollen and painful throat
  • frequent throat inflammation
  • spit thin and white phlegm
  • spit thick and yellowish phlegm
4. Breath, Heart & Blood Pressure
  • chest oppression
  • shortness of breath
  • slightly difficult breathing
  • middle degree difficulty in breathing
  • severe difficulty in breathing
  • slight palpitations
  • severe palpitations
  • stabbing pains in the heart
  • distention and discomfort of the right rib-side
  • having slight heart problem
  • having middle degree problem of the heart
  • having severe heart problem
  • having slight problem of the blood pressure
  • having middle degree problem of the blood pressure
  • having severe problem of the blood pressure
5. Stomach
  • stomach pains
  • stomach distention
  • burning stomachache
  • cold stomachache
  • shrinking sense of the stomach
  • stomachache likes warmth or warm drinks
  • stomachache likes pressure on it
  • wish to vomit
  • dropping sense of the stomach
  • belch with sour taste in the mouth
6. Abdomen & Kidney
  • lower abdomen pains
  • lower abdomen distention
  • lower abdominal pains like warmth and pressure
  • painful back with inability or difficulty to stretch or bend the back
  • aching pains of the shoulders and back
  • stiff and painful loins due to falling or sprain or hard physical work
  • dull pains of the loins
  • left kidney area pains
  • right kidney area pains
  • cold sense on the back
7. Limbs
  • stiff four limbs
  • general body pains
  • muscle spasm of the body
  • tight or spasmodic tendons of the general body
  • running pains of the body joints
  • heavy sense wrapping the body
  • swollen and painful joints of the arms
  • swollen and painful joints of the legs
  • edema of the lower limbs
  • edema of the general body
  • numbness of the four limbs
  • aversion to cold and cold limbs
  • hot sense in the soles and palms in the afternoon or night often
8. Sweat, Sleep & Appetite
  • day time sweat
  • sweat at night
  • insomnia
  • dreaminess
  • frequent waking up during sleep
  • thirst and like drinks
  • like cold drinks
  • like hot drinks
  • reduced appetite
  • easy hunger and excessive food-intake
  • hunger without desire to eat
  • eat much cold foods
  • eat much fast foods
  • irregular food intake
9. Urination
  • frequent daytime urination
  • urgency in urination
  • white urine
  • yellowish urine
  • dark yellow urine
  • thirst and like drinks
  • painful urination
  • frequent night urination
  • dribbling urine after urination
10. Constipation & others
  • constipation
  • diarrhea with burning sense at the anus
  • diarrhea with clear undigested foods
  • diarrhea worsened by emotional frustration or distress
  • diarrhea every 5 O'clock (AM) with abdominal pains
Wrist Pulse:
  • powerful pulse
  • weak pulse
  • 50 to 60 wrist beats per minute
  • 60 to 80 wrist beats per minute
  • 80 to 100 wrist beats per minute
  • 100 to 120 wrist beats per minute
  • thin pulse body like a thread
  • deep pulse
  • string-like pulse (touching the wrist pulse like touching a tight string of a musical instrument)
  • abnormal rhythm of pulse
Living Environment:
  • always a cold and windy living environment
  • damp living environment
  • dry living environment
  • 60 to 80 wrist beats per minute
Temperament and Emotions:
  • optimistic, open-minded and happy
  • pessimistic
  • melancholic
  • nervous often
  • overthinking often
  • lone and close-minded
  • easy to be angry always
  • depressed often
  • irritability often
Spirit and work:
  • fatigued
  • stressful work
  • too much stressful work
If you a male, please tick off here: If you a female, please tick off here:
  • reduced sexual ability
  • impotence
  • premature ejaculation
  • weak erection
  • seminal emission in the daytime
  • seminal emission at night
  • reduced desire of sex
  • frequent masturbation one to two years
  • frequent masturbation two to four years
  • frequent masturbation more than four years
  • testicle pains one side
  • testicle pains two sides
  • swollen scrotum
  • cold damp scrotum
  • itching scrotum
  • damp heat scrotum
  • private part with strong smell
  • pains of the perineum
  • burning sense in the urethra
  • excretion from the opening of the urethra
  • dropping sense of the anus
  • too strong sexual desire
  • sterility
  • reduced sexual desire
  • irregular menstruation
  • advanced menstruation
  • delayed menstruation
  • painful menstruation
  • too much amount of menstrual blood
  • too little amount of menstrual blood
  • burning sense in the womb
  • the womb like warmth and pressure
  • cold sense in the womb
  • thin color of the menstrual blood
  • deep red color of the menstrual blood
  • purplish color of the menstrual blood
  • menstrual blood clots
  • profuse and sudden uterine bleeding
  • gradual uterine bleeding
  • amenorrhea (stop of menstruation)
  • profuse and thin leucorrhoea
  • profuse, thick and yellow leucorrhoea
  • infertility
  • strong sexual desire
What kind of foods do you like? What are your daily foods? Do you smoke? What are your private hobby? Do your family members suffer the similar health problems?
If you have some clinical laboratory examinations, please offer the results. Also you could fax the documents of your laboratory check to our 86 745 2813349. Thanks.
What about your major complaints at present? Do you have the health problems of the heart and blood pressure? Serious or slight?
Do you wish to come to China to our hospital for better help? Let us know the approximate date of arrival, the approximate period of time to stay here. Please seek an official invitation letter from us now so that you could get a three months or six months visa of L-type or F-type for you and your accompanying persons.
If you are not able to be here, commonly there are four ways that we could help you.
The first choice is the prepared herbal products produced by hundreds different herbal companies in China. We have four hundreds different perfect herbal products for various commonly encountered diseases.
The second choice is raw herb tea. We could prescribe a special herbal formula for you, then mix the raw herbs. Please decoct the raw herbs to make herbal tea, drink the tea twice a day. The adult dosage is 200 milliliters each time. The first treatment course will be 20 days. We will air ship to you. The general cost for 20 days supply will be US$300.00 for you.
The third choice is herbal granule. We could prescribe a special herbal formula for you. The herbal granule is dissoluble and concentrated made through modern technology. Each dosage is composed of different sachets of granule. Please cut every sachet and put the granule into a cup. Put a little hot water into the cup and stir the herbal granule. For adult, after that please put another 250ml boiling water into the cup and stir it with spoon. You will get some liquid, drink it when it is cool or still warm. Please drink half of the liquid in the morning and another half of that in the afternoon. The general cost for 20 days will be US$280.00 for you.
The fourth choice is honey herb pills. We could make the herbal powder into honey herb candies for you. You could first order 20 days supply as the first treatment course. It is about 200 pills for you, about 10 grams each pill. The adult dosage is 3 to 4 pills each time, three times a day. We will air ship the package to you. The general cost for 20 days will be US$280.00 for you.
*Please let us know which choice you prefer.
The first choice The second choice The third choice The fourth choice
If you want an Internet Video meeting with our doctor by Skype, please let us know. The meeting takes about 30 to 50 minutes, so that we can know your detailed information of health directly. This meeting cost for you is US$50.00.
You'd better take three pictures of your tougue and one picture of your hand-back under the outdoor natural light.
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