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What is your main concern for this consultation? Any information will be helpful to the doctor in the evaluation.
Have you seen a physician or Traditional Chinese Medicine doctor for this condition? What is the diagnosis?
Have you taken any prescribed medicine or herbal remedies for this condition? If so, please provide the name, dosage, and the effects, if any.
Do you have any of the following?
Yes, Blood Sugar Level:
Yes, Cholesterol Level:
High Blood Pressure:
Yes, Blood Pressure Level:
Risk of Stroke:
Yes, Date of Last Stroke:
Yes. Please specify:
Yes. Please specify:
Yes. Please specify:
Do you have any other major medical conditions? If so, provide them in the box below.
Do you have any of the following conditions? Choose all that apply:
Pain: Distending Pain Bursting Pain Heaviness Pain Stabbing Pain Dull Pain Angina (colic) Tic Pain Burning Pain Cold Pain Emptiness Pain Throbbing Pain Rebounding Pain Bearing-down Pain Coagulating Pain Dragging Pain Referred Pain Radiating Pain Wandering Pain Slight Pain Soreness Pain Numbness Pain Stiffness Pain Spasm Pain Localized Pain Tenderness Pressing Pain Desire for pressure while in pain Detesting of pressure while in pain Desire for cold compress Desire for fomentation
Chills and Fever? (Choose all that apply: Aversion to cold with fever Aversion to cold as cold water sprinkling over body Furling Fever Heavy aversion to cold with light fever Heavy fever with light aversion to cold Fever with aversion to wind Alternating onset in chills and fever Alternating in shiver and ardert fever Relief of fever after sweating and continued relapse Prolonged unrecovery Fever without chill High fever Low fever Prolonged low fever Morning Fever Afternoon Fever Afternoon hectic fever Night high fever Feverish sensation to the head Feverish sensation of the five centers Feverish sensation over palm or sole Hot feeling on the dorsum of the hands or feet Recessive fever Hectic fever due to Yin-deficiency (bone-heat syndrome) Prolonged Fever Autopsychic fever under normal temperature Chill without fever Acrohypothermia Cold hands or feet Deadly cold hands or feet Chilly sensation of back Cold sensation of back (as if ice is covering back)
Perspiration (Sweat)? Intolerance to cold without sweating Aversion to wind with sweating Perspiration following chills Profuse perspiration Sweating as steaming Continuous sweating Spontaneous perspiration Night sweat Clammy sweat Warm perspiration Sweating on the forehead Greasy sweating Yellowish perspiration Cold limbs after sweating Sweating but without relief of fever Morbid perspiration over the head Morbid perspiration over the chest Perspiration around the external genitals Perspiration over the hands or feet Sweating during activities Sweating over left side of body Sweating over right side of body Sweating over lower half of body Sweating over left uper limb Sweating over right upper limb Sweating over left lower limb Sweating over right lower limb
Conditions of the Head and Body?: General headache Bilateral headache Migranous headache Helmet headache Frontal headache Occipital headache Occipital headache referring to neck and back Parietal headache Stiffness and pain of the neck and head Heaviness of head Dizziness Vertigo Intense headache and splitting flaccidity of neck Feeling of distention in the head Feverish sensation over the head Involuntary head shaking or twitching Seborrheic dermatitis Sounding inside the head Fracture of the skull or cranial bone Feeling of numbness on the scalp
Face and Eye: Itching of the face Numbness of the face Feverish sensation over cheeks or behind ear Dryness and uneasy feeling of the eye Photophobia Itching of the eye Eyeball pain Dimness of vision Hypopsia Diplopia (double vision) Photism Night blindness Supra-orbital pain Infra-orbital pain Maxillary pain Mandibular pain
Lips, Tongue, and Teeth: Itching of lips Numbness of lips Loss of sensation of lips Swollen lips Trembling lips Exfoliative inflammation of lips Lockjaw Chapped lips Dry lips Cyanosis of lips Itching of the tongue Numbness of the tongue Swollen tongue Pain in tongue Toothache Cold feeling of the tooth Feebleness of the tooth Bleeding gums Gingivitis
Ear, Nose, and Throat: Ringing in the ear A nosie in the ear as chipring, roaring, ringing Hard of hearing Deafness Poor auditory acuity Sudden loss of auditory acuity Gradual loss of auditory acuity Earache Itching in ear Heavy discharge from ear Heavy earwax Foreign body in ear Bleeding of ear Stuffy nose Itching nose Itching over tip of nose Pain of nose Dry nasal cavity Ozena Thick and yellowish nasal discharge Thin and whitish nasal discharge Epsitaxis Impairment of smell Anosmia Continued sneezing Occasional sneezing Sore throat Dry throat Itching throat Congested throat Swelling and pain in t hroat Wheezing sounds Obstruction of throat by sputum Ulceration of the pharynx
Trunk and Limbs: Ache or pain over the entire body Pain of shoulder and back Vague ache of the back and shoulder Lassitude ache of the shoulder and arm Pain on the scapular area Debility of neck Stiffness of nape Stiffness of nape and back Arthrodynia of the extremities General weakness Lassitude of limbs Heaviness of limbs General fatigue Numbness of limbs Cold clammy limbs Spasms of limbs Cramps of limbs Edema of limbs Flaccid paralysis of limbs Redness, swelling, heat, and pain of the joints Dyskinesia of the limbs Localized arthralgia Migratory arthralgia Pain that is aggravated by cold and relived by heat Pain that is aggravated by heat and relieved by cold Paralysis of limbs Weakness, limited movement, or muscular atrophy of limbs Ankylosis Arthrocele Deformity of joints Pain related to weather Chest and Hypochondria: Chest pain Feeling of oppression in chest Feeeling of fullness and dull pain in chest and upper abdomen Chest and back pain Feeling of fullness and oppression in the chest and hypochondria Hypochondriac pain Distending pain in the hypochondrium Fullness and rigidity of the hypochondrium Upset chest and hypochondria (vexation) Palpitation Severe palpitation Violent palpitation with irritability Palpitation with a feeling of pulling Restlessness Tachycardia Heart attack Heart diseases Cardiac failure
Conditions of Gastric Cavity: Stomachache Anorexia (loss of appetite) Frequent vomiting Distended stomach Upset stomach Feeling of obstruction in upper abdomen Epigastric distendign pain Feeling of fullness and dull pain in the upper abdomen Epigastric throb Epigastric pain Nausea Fullness and oppression of upper abdomen Feeling of emptiness, burning, and uneasiness in upper abdomen Acid regurgitation Eructation with foul odor Eructation Hiccup Vomiting Billious vomiting Hematemesis Regurgitation of milk Pain while eating Pain in anti cibum before meal Pain when hungry Pain in post cibum Desire for cold drinks Desire for hot drinks
Abdomen: Fullness of abdomen, flatulence Abdominal pain Borborygmus Mass in the abdomen
Lower back: Lumbago Pain of the back and loin Pain along the spinal column Lumbosacral pain Cool feeling on lower back Weak feeling in loin Limp feeling in loin Pain of the waist and lower extremities Pain on the left lower back or right lower back that radiates downward
Sleep: Difficulty falling asleep Sleeplessness Waking up early Easily woken up Sleep drunkenness Dreaminess Night terrors Nightmares Sleep-talking Sleep-walking Restlessness (Fidgeting)at night, peace during the day Sleepiness in the daytime Sleepiness Drowsiness Falling asleep quickly, but woken up easily Half asleep daze
Mental State Amnesia (forgetfulness) Oversensitive (Oversuspicious) Sentimental Depression Uncommunicative and melancholy Dysphoria Irritability Paraphronia Paraphobia Hypersomnia Sudden onsets of suffocating sensation Paraphasia Muteness Mania Demonstration with shouting or yelling Tearing off clothes and running about Smashing things and hitting people
Appetite and Taste: Thirst and desire for drinking but vomiting immediately after drinking Dryness of the mouth but only desire for gargling without swallowing Hunger without desire to eat Polyorexia No desire for eating Loss of apetite(anorexia) Abdominal distension after meal Bulemia Normal appetite Detesting greasy or sweet foods Craving for unusual foods (sour food, pungent food, raw rice, soil) Bitter taste in mouth Foul breath Flat taste in mouth Sweet taste in mouth Salty taste in mouth Sour taste in mouth Spoiled taste in mouth Excessive secretion of saliva Numbness of the mouth and lips Normal sense of the mouth Recent weight loss Recent weight gain
Vomiting and Hiccups: Nausea Hiccups Occassional onset of hiccups Frequent onset of hiccups Acute onset of hiccups Chronic onset of hiccups Eructation Vomiting after meals Evening vomiting with vomitus containing food eaten from morning Morning vomiting with vomitus containing food eaten the previous night Vomiting of food Vomiting of fluids Vomiting of bitter (bilious) fluid Vomiting of phlegm Regurgitation of milk Hematemesis Vomit with blood Copremesis Sour regurgitation
Urination and Defacation: Constipation Coprastasis Dry stool Dyschesia Dry stool followed by loose stool Loose stool and malaise of anus Stool burning anus Constipation with occassional watery discharge Impotency in defecation (Severe rectal tenesmus) Diarrhea after abdominal pain Sudden onset of watery diarrhea Watery diarrhea with ingested food in stool Fluid stools containing undigested food Diarrhea with purulent and bloody discharge Tenesmus Watery diarrhea Diarrhea before dawn Defecation ocne each day Defecation several times each day Defecation once every two or several days Loose and unformed stool Diarrhea with water in stool Diarrhea with yellow rottenness Diarrhea with sour rotten foul filthy discharge Tarry stool Discharged of feces followed by blood Discharge of blood followed by feces Burning sensation in anus during defecation Tenesmus sensation in anus or prolapse of anus Encopresis Clear urine Oliguria with reddish urine Turbid urine Yellowish or reddish urine Deep colored urine Cloudy white urine Urination with burning sensation Ardor urinae Difficulty and pain in micturition Irritable bladder Emergency of micturition Dripping discharge of urine Difficulty in micturition Retention of urine Oliguria Incontinence of urine Bed wetting Involuntary discharge of urine when sleeping at night Polyuria with watery urine Polyuria Polyuria at night Small urinary stream Blood in urine
Anterior and Posterior Orifice: Vilvitis Cold feeling of external genitals Swelling of female pudendum Prolapse of uterus Ulceration of external genitals Pruritus of female pudendum Vaginal bleeding Abnormally prolonged erection of the penis Inguinal hernia dropping to the scrotum Flaccid constriction of the penis Tinea inguinalis Impotence Seminal emission (weat dreams, emission) Nocturnal emission Premature ejaculation Prolonged erection of penis with spontaneous emission Shrinkage of scrotum Wetness of scrotum Pruritus of scrotum Painful and swollen testes Orchialgia Testicular atrophy Pain of the lower abdomen referring to the testes Pain of the anus Anal fissure Perianal abscess Anal fistula Prolapse of rectum
Menstruation and Leukorrhea: Polymenorrhea (Preceded menstrual period) Delayed or infrequent menstrual period Irregular mensturation Menostaxis (Prolonged menstrual period) Short menstrual period Profuse menstruation Scanty menstruation Oligomenorrhea Light colored menses Bright red menses Deep red menses Purple red colored menses Lump menses Difficult menstruation Abdominal pain before, during, or after menstruation Lumbosacral pain before, during, or after menstration Mania before, during, or after menstruation Delirium before, during, or after menstruation Fever before, during, or after menstruation Vomiting before, during, or after menstration Edema before, during, or after menstruation Hematemesis before, during, or after menstruation Retrograde menstruation Hemafecia before, during, or after menstruation Bodily pain before, during, or after menstruation Diarrhea before, during, or after menstration Epistaxis and hematemesis before, during, or after mensturation Amenorrhea (suppressed menstruation) Amenorrhea accompanied with edema Latent menstruation Thin leukorrhagia Thick leukorrhagia Whitish abnormal vaginal discharge Greenish abnormal vaginal discharge Reddish abnormal vaginal discharge Leukorrhagia with reddish and whitish discharge Leukorrhea with yellowish discharge Foul smelling leukorrhea Leukorrhea
If you have any other conditions that were not stated above, please list them below:
Have you paid the $40 fee for this consultation?
Yes. No. Waived fee.