Digestion Disorder E-Consultation Form

Name

First NameLast Name

Age

Gender

Height (cm)

Weight (lb)

Occupation

Email

example@example.com

Phone Number

Area CodePhone Number

Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please describe your current problem, including symptoms, which you are looking for Dr Huang’s herbal remedy to assist in healing or recovery

Are you currently taking any medications, or supplements (including vitamins)?

Please include ALL medications/supplements/vitamins

Previous Hospitalization

Provide the reason and treatment

Do you have any allergies?

Rows	No	Yes	Details (if you answered ‘Yes’)
Food
Environmental
Medication
No known allergies
Other

Mark the medical conditions that apply to you

Rows	No	Yes	Details (if you answered ‘Yes’)
Do you always feel cold or hot, chills, or fever?
Do you have day sweating or night sweating?
Do you have a dry mouth or always feel thirsty?
Do you feel a bitter or other taste in your mouth?
Do you prefer cold drinks and/or food?
Do you prefer hot drinks and/or food?
Do you feel tired or fatigued?
Do you feel stress, anxiety, or depression?
Do you have cold hands and/or feet?
Do you have high blood pressure, high blood cholesterol, or diabetes? Please add the details.
Do you have a tumor or cancer?
Did you gain weight recently?
Did you lose weight recently?
Do you have any bleeding?
Do you have jaundice?

1. Do you have stomach cramps?

1.1 Frequency of stomach cramps

1.2 Stomach cramps are aggravated by

1.3 Stomach cramps are relieved by

2. Do you have stomach bloating?

2.1 Frequency of stomach bloating

2.2 Stomach bloating is aggravated by

2.3 Stomach bloating is relieved by

3. Do you feel gas in your stomach?

3.1 Frequency of feeling gas in your stomach

3.2 Stomach gas is aggravated by

3.3 Stomach gas is relieved by

4. Do you have belching or hiccups?

4.1 Frequency of belching or hiccups

4.2 Belching or hiccups are aggravated by

4.3 Belching or hiccups are relieved by

5. Do you have nausea or vomiting?

5.1 Frequency of nausea or vomiting

5.2 Nausea or vomiting is aggravated by

5.3 Nausea or vomiting is relieved by

6. Do you have diarrhea?

6.1 Frequency of diarrhea

6.2 Do you have stomach cramps with diarrhea?

6.3 Is your diarrhea watery or loose stool?

6.4 Is your diarrhea bloody or does it have mucus?

6.5 Do you have anus pain with diarrhea?

6.6 The diarrhea is aggravated by

6.7 The diarrhea is relieved by

7. Do you have constipation?

7.1 Frequency of bowel movements when you are contipated

7.2 Is the stool very hard or sluggish?

7.4 Any bleeding or mucus in the stool?

7.3 Do you have stomach bloating or gas with constipation?

7.5 The constipation is aggravated by

7.6 The constipation is relieved by

8. Do you have poor appetite？

8.1 Frequency of poor appetite

8.2 The poor appetite is aggravated by

8.3 The poor appetite is relieved by

9. Do you have heartburn or acid reflux?

9.1 Frequency of heartburn or acid reflux

9.2 The heartburn or acid reflux is aggravated by

9.3 The heartburn or acid reflux is relieved by

10. Do you have bad breath?

10.1 Frequency of bad breath

10.2 The bad breath is aggravated by

10.3 The bad breath is relieved by

11. Alcohol Consumption

12. Do you smoke?

Exam results (if applicable )

Rows	Don't know	Normal	Abnormal	Details
Liver exam (blood test, ultrasound, CT scan)
Gallbladder exam (X-RAY, ultrasound, CT scan)
Stomach exam (X-RAY, ultrasound, CT scan)
Intestine exam (X-RAY, ultrasound, CT scan)
Esophagus exam (X-RAY, ultrasound, CT scan)

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

Browse Files

Signature

Payment

E-consultation fee$60.00 CAD

Total $0.00 CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Date Signed

Date

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

Patient Information

Medical Data

Assessment

Payment

Patient Information

Medical Data

Assessment

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