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HESHOUTANG TCM Online Patient Symptoms Analysis Form for Common Diseases

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. (Note:Your Correct Email Address Required)

Personal Information

  • Name:*
  • Email:*
  • Height: feet
  • Blood Pressure:
  • Address:
  • Zip Code:
  • Phone:
  • Age:
  • Gender: M F
  • Weight: lbs
  • Blood Sugar:
  • City/State:
  • Country:
  • Occupation:
  • Chief Complaint:
  • Current illness period:Months

Please Check the boxes below relevant to your symptoms:

  • Stomach and Spleen:
  • (1)Appetite?
  • Normal
  • Strong
  • Low
  • No appetite
  • (2)Stomach ache?
  • Dull Pain
  • Sharp Pain
  • Pain relieve
  • More serious after eating
  • (3)Stomach distention?
  • No
  • Yes
  • (4)Acid stomach(burning heart)?
  • No
  • Slight
  • Serious
  • (5)Gastric acid reflux?
  • No
  • Slight
  • Serious
  • (6)Dry mouth?
  • No
  • Yes
  • (7)What's the taste in your mouth?
  • Normal
  • Sweet
  • Bitter
  • Sour
  • Salty
  • (8)Bad breath?
  • No
  • Slight
  • Serious
  • (9)Vomiting Problems?
  • A little
  • Retching
  • Vomiting undigested food
  • Vomiting thin phlegm
  • (10)Often thirsty?
  • No
  • Yes
  • (11)Prefer food?
  • Cold drinks(food)
  • Hot drinks(food)
  • Lung and Large intestine:
  • (1)Cough?
  • No
  • Slight
  • Serious
  • (2)How long?
  • Less than 15 days
  • 15-30 days
  • 1-3 months
  • 3-6 months
  • More than 6 months
  • (3)Have Phlegm?
  • No
  • Thin and White
  • Thick yellow
  • (4)When you have cough or serious cough?
  • Day time
  • Night time
  • Spring
  • Summer
  • Autumn
  • Winter
  • (5)Short of breath?
  • No
  • Slight
  • Serious
  • (6)Asthma?
  • No
  • Slight
  • Serious
  • (7)Chest oppression?
  • No
  • Slight
  • Serious
  • (8)Throat problems?
  • No
  • Dry
  • Itching
  • Painful
  • (9)Sweat easily(except work and exercise)?
  • No
  • Daytime sweating
  • Sticky sweating
  • Night time sweating
  • (10)Skin problems?
  • No
  • Dry
  • Itching
  • Acne
  • (11)Excretion problems?
  • Normal
  • Constipation:Always very hard
  • Constipation:Hard only at the beginning
  • Diarrhea:Loose stool
  • Diarrhea:Watery stool
  • Diarrhea:Dawn diarrhea
  • Kidney and Bladder:
  • (1)Waist pain?
  • No
  • Sore pain
  • Sharp pain
  • (2)Listening problems?
  • No
  • Ear ringing
  • Deaf
  • (3)Frequent urine?
  • 5-6 times/daytime
  • 6> times/daytime
  • 1-2 times/night
  • >=3 times/night
  • (4)Urine color?
  • Normal
  • Yellow
  • Dark Yellow
  • Proteinuria
  • Chyluria
  • Blood urine
  • (5)Other urine problems?
  • No
  • Painful urine
  • Urgency of urination
  • Urethral burning
  • Dripping & retention of urine
  • (6)Sex problems for male?
  • ---Sex desire:
  • Normal
  • Weak
  • Strong
  • ---ED(erectile dysfunction)problem:
  • No
  • Slight
  • Serious
  • ---PE(premature ejaculation)problem:
  • No
  • <5 mins
  • <1 min
  • ---Infertility:
  • No
  • Yes
  • ---Sperm quality:
  • Normal
  • Less sperm count
  • Low sperm vitality
  • ---Seminal fluid quality:
  • Sticky sperm
  • Thin or wartery
  • Non-liquefaction
  • Aspermia
  • Liver and Gallbladder:
  • (1)Uncomfortable in the ribs area?
  • No
  • Yes
  • (2)Easily angry?
  • No
  • Yes
  • (3)Depressed often?
  • No
  • Yes
  • (4)Four limbs numb?
  • No
  • Yes
  • (5)Fragile fingernail?
  • No
  • Yes
  • (6)Headache?
  • No
  • In both sides of head
  • In the top of head
  • In the back of head
  • In the forehead
  • (7)Eyes problems?
  • No
  • Tearing on exposure
  • Blurred
  • Cloted eye
  • Itching
  • Pain
  • (8)Dizziness?
  • No
  • Yes
  • Heart and Small Intestine:
  • (1)Palpitation?
  • No
  • Slight
  • Serious
  • (2)Arrhythmia?
  • No
  • Slight
  • Serious
  • (3)Angina?
  • No
  • Slight
  • Serious
  • (4)Insomnia?
  • No
  • Slight
  • Serious
  • (5)Dreamful?
  • No
  • Slight
  • Serious
  • (6)Heart attack history?
  • No
  • Yes
  • For female only:
  • (1)Menses period time?
  • Normal
  • Always advanced
  • Always delayed
  • (2)Menses period duration?
  • Normal(3-7days)
  • <3 days
  • 7-15 days
  • >5 days
  • (3)Menses amount?
  • Normal
  • Less
  • Much
  • (4)Having blood clot?
  • No
  • Yes
  • (5)Menses color?
  • Normal(fresh red)
  • Slight red
  • Dark red
  • (6)Menses smell?
  • Normal
  • Strong smell
  • (7)Painful menstruation?
  • No
  • Pain before menses
  • Pain within menses
  • Pain after menses
  • (8)Whites?
  • Normal
  • White
  • Yellow
  • Red
  • Sticky
  • Curd
  • Smell bad
  • Less
  • Much
  • Thin
  • Thick
  • (9)Infertility?
  • No
  • Yes
  • Other problems:
  • (1)Stone?
  • No
  • In gallbladder
  • In kidney
  • In bladder
  • (2)Hair problem?
  • No
  • Slight lose hair
  • Serious lose
  • Dry & Split-ends
  • Much scurf
  • Oil scurf
  • (3)Toothache?
  • No
  • Yes
  • (4)Dental ulcer?
  • No
  • Yes

    (5)If you have any other problems,please write in the following:

    (6)Please describe your emotion problem,treatment history(such as what medicine you are taking now,the name and the efficacy of the medicine you take,what surgery did you have),your eating habits(such as like vegetables or meat,salty or sweet,irregular dood taking),exercise etc......?

  • Before submitting your form, please check if you have correctly filled out your email address. Thanks.

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