This Online Analysis service is to gather information to establish your illness.
Our Panel of TCM Doctors will examine the symptoms you submit here and prescribe the relevant
Chinese herbal products suitable for your treatment.
For accurate assessment by our Traditional Chinese Medicine Doctors, Please read the questions carefully and tick off the items correctly and as
accurately as possible so that our professional Doctors can diagnose your condition fully and prescribe effective an treatment for you.
Please allow 3 - 4 days for assessment results.
Personal Information
Email:
Name:
Gender:
Marriage Status:
Age:
years
Height:
Meters
Address:
City:
State:
Country:
Postal(zip) code:
Telephone:
Skype:
MSN:
Occupation:
Weight:
Kgs
Do you have children
Current illness period
Months
Please Check the boxes below relevant to your symptoms:
headache great hair loss slight hair loss hair loss with oily scalp blurred vision blood-shot eyes dizziness ringing in ear hearing loss pale complexion swollen and painful nose runny nose thin and white nasal discharge thick and yellowish discharge blocked nose a bitter taste in the mouth sour taste in the mouth dry lips slightly reddish tongue slightly whitish tongue deep-red tongue fissured tongue 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 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 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 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 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 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 day time sweat sweat at night insomnia dreaminess
Your Habits: Check the box if you Smoke cigarettes Cigerettes per day 10 - 20 Cigerettes per day 21 - 40 Cigerettes per day 40 Plus How many years have you smoked? Check the box if you drink alcohol How many alcohol drinks per week?
insomina constantly thirsty prefer cold drink prefer hot drink reduced appetite constantly hungry no desire to eat eat lot of cold foods diet consist mostly of fast food irregular food intake frequent daytime urination urgency in urination clear urine yellowish urine dark yellow urine painful urination frequent night urination dribbling after urination constipation diarrhea with burning sense at the anus diarrhea with clear undigested foods diarrhea worsened by emotional frustration or distress constant early morning diarrhea with abdominal pain (3-5am) If you are a male, please complete the following: reduced sexual ability impotence premature ejaculation weak erection seminal emission in the daytime seminal emission at night reduced sexual desire 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 odour 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
If you are a female, please complete the following: 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 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 Temperament and Emotions: optimistic, open-minded and happy pessimistic melancholic always worrisome nervous often over thinking often lone and close-minded easy to be angry always depressed often irritability often
Spirit and work: fatigued stressful work too much stressful work
Do you have any major complaints at present?
Such as heart, blood pressure or other?
Please explain more in the box below and indicate if this is Serious or slight?
What kind of foods do you like?
What are your daily foods?
If you smoke, how many per day?
If you drink alcohol, what kind and how often?
What are your private hobby?
Do your family members suffer the similar health problems?
If you have some clinical laboratory examinations, Blood Test results, etc, please offer the
results.
Also you could fax the documents of your laboratory check to us.
What about current or past prescribed medications, and their effects?
Any past hospitalizations for this or other diseases?
Do you suffer from other internal diseases?
If you do, please describe the degree of seriousness.
There are 2 options for your treatment.
1. You may wish to come to China to our hospital for better help? If you do, we can arrange everything for you.
You just have to let us know the approximate time you would be able to travel to us, and how long you are able to stay
2. If you would prefer our home treatment, which we make specifically from Chinese herbs, formulated specifically for your condition by our Doctors.
These are supplied as powders which you make as a herbal tea at your home.
Please indicate your preference below
Before submitting your form, please check if you have correctly filled out your email address. Thanks.
