Online Consultation

This form is only for the purpose of initial health consultation. The personal ID information will be strictly kept confidential, and only accessible to the health consultant. It is NOT released to any other parties without written permission from the clients.

For some questions, you can leave it blank If you are not sure or not applicable. This questionnaire will be used as initial case records to be compared with the changes and effects during the treatment process.

Please fill the form to the best you can and our clinic experts will be in touch with you to discuss your symptoms and possible treatment strategy. If any questions, please contact us.

Once the questionnaire is lodged, our specialists will be in touch with you shortly.

    Name *

    Email *

    Phone *

    Gender *

    Age

    Profession

    Main complaint & symptoms

    Any existing diagnosis

    How long since the onset of symptoms?

    When is it exacerbated, or induced?

    Treatments received

    Treatment progress

    Current medications

    Any of the following symptoms

    Any sleep issues

    Past medical history

    Occurrence period

    Treatment methods and efficacy

    Family health history

    History of allergies

    Any major mental stress?

    How do you feel when stressed?

    Length and extent of the mental stress

    Menstrual conditions (For females only)

    Menopausal hot flashes

    Fertility Status

    Please upload a photo of your tongue *


    Up to 10 MB

    Please upload photo of your face *


    Up to 10 MB

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