Free Health Evaluation
Please tell us about yourself. This information is for our records only, and is considered strictly confidential!

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Please check each symptom as they apply to you; we will get back to you within a few days with a Traditional Chinese Medicine diagnosis and recommendations; Thank you!

***Please be aware that these recommendations should not replace a western medical diagnosis.***

Name:		Date:
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Main complaint:		Age:
Male Female

Afternoon fever        Asthmatic breathing        Bad breath        Belching        Big appetite – get hungry easily        Bloating        Bloating especially after meals        Burning sensation and pain in stomach area        Chest pain        Chills        Clear, dilute phlegm        Cold limbs        Constipation        Cough        Cough with white phlegm        Difficulty falling asleep        Dislike wind        Distending or wandering pain in flank area        Distention of breasts        Dizziness, vertigo        Dream-disturbed sleep        Dry cough        Dry heaves/vomiting        Dry mouth        Dull pain in abdomen better with warmth/pressure        Empty and uncomfortable feeling in the stomach        Flushed face        Gurgling with phlegm in throat        Heat in palms and soles of feet        Hunger with no real desire to eat

Irregular menstruation or lack of menstruation        Irritability        Lack of desire to talk        Lassitude        Listlessness        Loose stool        Low voice        Mental depression        Mental restlessness        Mouth and tongue sores        Night sweating        Pale face        Palpitations        Poor appetite        Poor memory        Preference for cold drinks        Reduced urine output        Sensation of foreign object in the throat        Shortness of breath (worse on exertion)        Shortness of breath on exertion        Sour regurgitation        Spontaneous sweating        Stuffiness of chest        Swelling and pain or sore and bleeding of gums        Thirst        Vomiting        Weak cough        Yellow phlegm        Yellow urine

Other: