Three High Diseases E-Consultation Form

  • Patient Information

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  • Common Questions

  • Do you have a dry mouth or a bitter taste in your mouth?*
  • Do you prefer to drink*
  • How are your bowel movements？*
  • What is the color of your urine first thing in the moring?*
  • How often do you get up to urinate during the night?*
  • How is the quality of your sleep?*
  • How is your energy?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do you have?*
  • Do your hands and feet always feel cold ?*
  • Do you have migraines or headaches?*
  • The main purpose of this consultation is for*
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  • 3. Is there a family history of diabetes? (if “yes”, provide details)*
  • 4. Do you have increased thirst? (if “yes”, provide details)*
  • 5. Do you have increased hunger? (if “yes”, provide details)*
  • 6. Do you have frequent urination (especially at night?) (if “yes”, provide details)*
  • 7. Have you noticed unexplained weight loss? (if “yes”, provide details)*
  • 8. Do you have frequent fatigue? (if “yes”, provide details)*
  • 9. Do you have recurrent vaginitis?（for female）(if “yes”, provide details)
  • 10. Do you have difficulty with erections (for male) (if “yes”, provide details)
  • 11. Do you have blurred vision? (if “yes”, provide details)*
  • 12. Do you have tingling or numbness in your hands or feet? (if “yes”, provide details)*
  • 13. Do you have slow-healing wounds? (if “yes”, provide details)*
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  • 2. When is your daily blood pressure higher?*
  • 3. Is there a family history of high blood pressure, heart attack, or stroke? (if “yes”, provide details)*
  • 4. Do you have an inactive lifestyle? (if “yes”, provide details)*
  • 5. How much alcohol (beer, wine, liquor) do you consume on an average day?*
  • 6. How often do you add salt to your food?*
  • 7. Do you use any of these medications: birth control pills, steroids, decongestants, and anti-inflammatories? (if "yes", provide details)*
  • 8. Do you have frequent blurred vision? (if "yes", provide details)*
  • 9. Do you have frequent tinnitus (ringing of the ears) (if "yes", provide details)*
  • 10. Do you have frequent dizziness and or headache? (if "yes", provide details)*
  • 11. Do you have any edema in your feet or legs, or puffy eyelids in the morning? (if "yes", provide details)*
  • 12. Do you have a bad temper, or are easily irritated or angered? (if "yes", provide details)*
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  • 2. Do you have a family history of high blood cholesterol?*
  • 4. Do you have an inactive lifestyle? (if “yes”, provide details)*
  • 5. How much alcohol (beer, wine, liquor) do you consume on an average day?*
  • 6. How often do you add salt to your food?*
  • 7. Do you always feel tired or fatigued? (if "yes", provide details)*
  • 8. Are you frequently drowsy or dizzy? (if "yes", provide details)*
  • 9. Do you have excess phlegm or mucous? (if "yes", provide details)*
  • 10. Do you have fatty liver?  (if "yes", provide details)*
  • 11. Do you have diabetes and or high blood pressure? (if "yes", provide details)*
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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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