Do you have any of the following?

Diabetes:
Yes, Blood Sugar Level:
No
Not sure

Liver Disease:

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

Women Only

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.