Order Number: *

Your Name/ Nickname: *

Email Address: *

What specific physical conditions would you like to improve?*

1. Are You: *

Male
Female

2. Your Age? *

18-30
30-39
40-49
50-59
60-69
70+

PART 1. Dietary Situation

1. The condition of drinking water: *

Drinking a lot of water every day
Drinking very little water every day
Frequently feeling thirsty but not wanting to drink water
Frequently feeling thirsty and drinking a large amount of water
Normal water intake

2. Prefer to drink: *

Cold water
Warm or hot water
No particular preference

3. Appetite: *

Good
Ordinary
Not very good
Eat a lot but get hungry easily.
Want to eat but can't eat

4. Any following situation? (multiple choice) *

Burp
Acid reflux
Bloating
Bad breath
Nausea
Esophageal burning
Feeling of heartburn in the stomach
None of the above

PART 2. The Condition of Bowel Movements and Urination

1. Bowel movement: *

Once a day
Several times a day
Once every few days
Chronic constipation

2. Stool shape: *

Spherical
Thin and string-like
Unformed
Normal

3. Stool consistency: *

Somewhat dry
Somewhat loose
Sticks to the toilet bowl
Diarrhea
Normal

4. Urine: (multiple choice) *

PART 3. Sleep and Emotions

1. Falling asleep: *

Difficult
Not difficult

2. Sleep quality *

Deep sleep
Light sleep
Periodic insomnia

3. Waking up at night frequently occurs: *

23pm-1am
1am-3am
3am-5am
5am-7am
None

4. Dreams *

Sometimes having many dreams
Few dreams
Dreamless

5. Any following situation? (multiple choice) *

Feeling sleepy during the day
Feeling sleepy in the afternoon
Feeling sleepy after meals
Feeling mentally exhausted
Hypersomnia
Drooling while sleeping
None of the above

6. Emotions: (multiple choice) *

PART 4. Physical sensations

1. Body sensation: (multiple choice) *

Fear of cold
Intolerance to heat
Sensitive to wind
Feeling alternately cold and hot
Upper body feels hot while the lower body feels cold
Feeling of hot flushes in the afternoon
None of the above

2. Hands and feet: *

Cold hands and feet
Hot hands and feet
Cold fingertips
Hot and burning sensation in the palms of the hands and soles of the feet
None of the above

3. Sweating (including a damp sensation on the body): (multiple choice) *

Prone to sweating
Sweating profusely with slight activity
Hardly sweating
Obvious sweating on the palms of the hands and soles of the feet
Sweating on half side of the body.
Sweating only on the head
Prone to night sweats while sleeping
None of the above

4. Is there any of the following conditions in the chest and abdomen? (multiple choice) *

5. Lifestyle habits: (multiple choice) *

Fondness for spicy food
Chronic alcoholism
Irregular meal times
Prolonged sitting at work
Frequent sexual activity
Frequent masturbation
Chronic sleep deprivation
Smoking
None of the above

PART 5. Gender-specific questions

1. Have you gone through menopause? *

Yes
No

1.1. Number of days between periods: *

Irregular
Less than 20 days
21-35 days
36-60 days
More than 61 days

1.2. Do you experience menstrual pain? *

Yes
No

1.3. Menstrual clots: *

Presence of menstrual clots
None

1.4. Premenstrual feelings: (multiple choice) *

Breast pain
Lumbar soreness
Lower abdominal heaviness
Headache
None of the above

2. Special phase: *

Planning for pregnancy
Pregnancy
Breastfeeding period
Menstrual period
Menopause
Normal

1. Issues related to sexual function: (multiple choice) *

Premature Ejaculation
Erectile Dysfunction
Weak erection
Absence of morning erections
Frequent nocturnal emissions
Frequent spermatorrhea
None of the above

2. Issues related to men's health: *

Infertility
Prostatitis
Epididymitis
Orchitis
Urethritis
None of the above

PART 6. Any additional information about your health condition

PART 7. Tongue Coating

Upload a photo of your tongue coating. This is not mandatory, but we strongly recommend doing so, as it will help us diagnose your condition more intuitively.

Select a file or drag it here..

Supported formats：JPG、JPEG、PNG、GIF、pdf。

temp-for-74436-file2-1_

Example of tongue coating photo:

Tongue

Relax and display the entire surface of the tongue under natural light, ensuring that the image is clear.

TCM Consultation Form

1. Please fill out the Form based on your actual physical condition. Our suggestions will be based on the information provided.

2. Your information will be used solely for this consultation and will be kept completely confidential.

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