What is your major concerns for this consultation?
describe main symptomes or/and diagnosed disease with duration.

What is the course of your sufferings ?
When did this problem begin? What is the trigger of this problem? What kinds of treatment (western and Chinese) have you tried? What makes this problem worse/better?

What is your and your family's medical histories?
1.Disease info:cancer,diabetes,hepatitis, thyroid disese, seizure, arthritis, breathing problems, heart disease, digestive disease, venereal disease, alcoholism, depression, tuberculosis, high cholesterol, high blood pressure, emotioanl disorders, anemia, others. 2.Medicine info: vitamins, herbs, etc.

What is your personal life history?
habits (eg smoking, exercise),diet,living environment

What are your general manifestations?
fever; chill; night sweats; sweat easily; fatigue; weight loss;
weight gain; favor morning of a day; favor evening of a day; weak voice;
sleepiness; difficulty falling asleep

What about your head and face?
dizziness; concussion; migraine; frontal headache; Vertex headache; occipital headache; eye pain; dry eyes; night blindness; blurry vision;
red eye; sudden onset tinnitus; chronic tinnitus; poor hearing;
nose bleeding; sore throat; teeth problems; facial pain; hair loss;
sores on lips/tongue; pale face; others

What about your body and limbs?
itching; rashes; ulcerations; dry skin; muscle weakness; pain in the muscles; joint pain; tremors; cold limbs; difficulty walking; swelling limbs; numbness; tingling in fixed areas; moving pain in some areas; dull pain in some areas; pain relief with pressure; pain aggravated with pressure; others

What about your cardiovascular system?
high blood pressure; low blood pressure; palpitation; fainting; irregular heartbeat; rapid heartbeat; varicose veins; others

What about your respiratory system?
cough with white phlegm; cough with yellow phlegm; cough with bloody phlegm; dry cough; wheezing; asthma; short breathing

What about your gastrointestinal system?
poor appetite; nausea; vomiting; diarrhea; constipation; bloating; belching; black stool; loose stool; bloody stool; dry stool; bad breath; hemorrhoids; anal burning

What about your genitourinary system?
painful urination; frequent urination; urgent urination; bloody urination; urinary dripping; pause of flow; unable to hold urine
For females only: pain prior to periods; pain during periods; pain after periods; irregular periods; hot flash; breast distention; in pregnacy; in lactation; miscarriage; abortion; C-section
For males only: premature ejaculation; weak erection; excessive sexual drive; loss of sexual drive; emission; active sexual life

What about your neuropsychological system?
loss of balance; poor memory; concussion; depression; anxiety; stress; bad temper; others

A photo of your face and tongue would be helpful for online evaluation if on-site visit is not possible. You can email to jianyan@oneclinicexpress.com.

Do you have other concerns about your health?