General E-Consultation Form

Patient Information
Name*

First NameLast Name
Gender
Age*
Occupation*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical Data
Please describe your current problem, including symptoms, which you are looking for Dr Huang’s herbal remedy to assist in healing or recovery*

Do you have any allergies?

	No	Yes	Detail (Apply for answer Yes)
Food
Environmental
Medication
No known allergies
Other

Are you currently taking any medications, or supplements (including vitamins)?*
Please include ALL medications/supplements/vitamins
Existing Medical Problems/Conditions*
Previous Hospitalization *
Provide the reason and treatment
Family History Illnesses*

AsthmaCardiovascular DiseaseDiabetes MellitusHypertensionTuberculosisOther
Assessment

Mark the medical conditions that apply to you*

	Yes	No	Details
Do you always feel cold or hot, chills, or fever?
Do you have day sweating or night sweating?
Do you have: cough, chest tightness, or heart palpitations?
Do you feel stress, anxiety, or depression?
Do you have any of these stomach problems: pain, indigestion, bloating, or craving?
Do you have migraines or headaches?
Do you have cold hands and/or feet in winter?
Do you have high blood pressure, high blood cholesterol, diabetes? Details.
Do you have sore lower back or sore knees?
Is there anything that reduces the level of severity of your condition?
Is the severity level related to time, season, change in weather, or location?
Is the severity level related to stress or mood changes?
For women: is the severity level related to your menstrual cycle?

Brief medical conditions that apply to you*

	Details
Are your bowel movements regular, or do you have constipation or chronic diarrhea?
What is the color of your urine first thing in the morning?
How often do you get up to urinate during the night?
How is the quality of your sleep?
How is your energy?
How is your digestion?
Are there any specific details, worries, or concerns you need mention to Dr Huang?

Tongue Picture （Please upload your tongue pictures following the examples above）*

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Payment*

E-consultation fee$60.00CAD

Total $0.00CAD

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Date Signed*

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Contact Us

AAHC-Ankang Acupuncture Healing Centre

Tel: 204-775-2266

Clinic website: https://acupuncturewinnipeg.ca

E-mail: ankangacupuncture@gmail.com

Add: 689 St Mary's Rd, Winnipeg, Manitoba, Canada
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