7TCM Online Consultation Form

Please fill out the following Traditional Chinese Medicine (TCM) consultation form. Our medical team will communicate with you in real-time via email and develop the most suitable treatment plan based on your condition.
You may also download the form, fill it out, and email it to [email protected].

Name:
Gender:
Age:
Country:
Address:
Email:
Phone:
Other Contact Methods:
Body Temperature:
Heart Rate:
Blood Pressure:
Duration of Illness:
Main Symptoms:
Cold/Heat
Fear of Cold:
Fear of Wind:
Fear of Heat:
Alternating Fever and Chills:
Exterior Heat with Interior Cold:
Sweating
Sweating:
Sweating Location:
Head
Headache:
Dizziness/Vertigo:
Stiff Neck/Back:
Dry Nose:
Nasal Congestion:
Runny Nose:
Clear or Turbid Nasal Discharge:
Sore Under Nose:
Mouth
Bitter Taste:
Bad Breath:
Toothache:
Thirst
Thirst/Dry Mouth:
Prefer Cold or Hot Water:
Water Intake:
Vomiting
Dry Heaving:
Vomiting:
Throat
Sore Throat:
Dry Throat:
Foreign Object Sensation:
Cough
Coughing:
Phlegm:
Clear or Turbid Phlegm:
Persistent Asthma:
Ears
Ear Blockage:
Deafness:
Tinnitus:
Body
Sores/Rashes:
Body Pain:
Lower Back Pain:
Bone/Joint Pain:
Restlessness:
Yellowing Skin:
Abdominal Fullness/Heaviness:
Numb Mouth/Face:
Any Body Pain:
Chest/Heart
Irritability:
Palpitations:
Chest Fullness:
Rebellious Qi in Chest:
Anxiety (Heart Oppression):
Shortness of Breath:
Lack of Qi:
Hardness Under Chest:
Chest Pain:
Pain Under Chest:
Hard Lump Under Chest:
Whiplike Pain Under Chest:
Fullness Under Chest (No Pain):
Nausea:
Feverish Sensation in Chest:
Qi Rushing Toward Heart:
Burning/Hot Sensation in Heart:
Ribs
Rib Pain:
Hardness in Rib Area:
Water Qi Under Ribs:
Abdomen
Abdominal Pain:
Abdominal Mass:
Palpitation Under Navel:
Urgent Urge to Defecate:
Rumbling Sound in Abdomen:
Back
Back Pain:
Aversion to Cold on Back:
Limbs
Cold Hands/Feet:
Difficulty Stretching Limbs:
Leg Cramps:
Heavy Pain in Limbs:
Urination
Difficulty Urinating:
Frequent Urination:
Urgency to Urinate:
Involuntary Urination:
Urine Color:
Urine Volume:
Bowel Movements
Constipation:
Diarrhea:
Incomplete Evacuation:
Sticky Stool:
Pus/Blood in Stool:
Diet
Acid Regurgitation:
Stomach Distention:
Vomiting After Eating:
Lack of Appetite:
Sleep
Insomnia:
Easily Awakened:
Sleepiness:
Spirit
Incoherence:
Feverish Talk:
Weary/Drowsy:
Irritability:
Medical History
Past Medical History:
Cause
Known Cause of Illness:
Women's Menstruation
Menstrual Cycle (Normal/Early/Delayed/Irregular):
Menstrual Blood Color:
Blood Clots:
Dysmenorrhea:
Other Discomforts During Menstruation:
Vaginal Discharge:
Vaginal Discharge Color:
Vaginal Discharge Volume (Large/Small):
Odor:
Breast Hyperplasia:
Tongue Color
Tongue Color:
Facial Color
Normal:
Red:
White:
Blue:
Black:
Pulse
Floating Pulse:
Tight Pulse:
Strong/Forceful Pulse:
Deep Pulse:
Slippery Pulse:
Fine/Weak Pulse:
Daily Routine
Sleep Time:
Wake-up Time:
Daily Work:
Additional Instructions:
Remarks:
Music Therapy:
Exercise Therapy:
TCM Therapy:
Art Therapy:
Tea Therapy:
Home Consultation Services
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