Three High Diseases E-Consultation Form

Name *

First Name Last Name

Age *

Occupation *

Height (cm) *

Weight (lb) *

Phone Number *

Area Code Phone Number

Email *

example@example.com

Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Do you have a dry mouth or a bitter taste in your mouth? *

Dry mouth Bitter taste Neither

Do you prefer to drink *

Cold water Room temperature water Warm water

How are your bowel movements？ *

Regular (1~2 times a day) Constipation (once per 2~3 days） Chronic diarrhea (loose stool 3~5 times a day)

What is the color of your urine first thing in the moring? *

Dark yellow Light regular yellow Light clear

How often do you get up to urinate during the night? *

1~2 times 2~3 times More than 3 times None of these

How is the quality of your sleep? *

Good Wake up easily Dreaming

How is your energy? *

Good Medium Low Very low

Do you have? *

Sore lower back Sore knees None of these

Do you have? *

Stress Anxiety Depression None of these

Do you have? *

Night sweating Hot flashes Day sweating None of these

Do you have? *

Cough Chest tightness Heart palpitations None of these

Do you have? *

Stomach pain Indigestion Stomach bloating Craving None of these

Do your hands and feet always feel cold ? *

Yes No

Do you have migraines or headaches? *

Yes No

Do you have any allergies? (if “yes”, provide details) *

The main purpose of this consultation is for *

High blood sugar High blood pressure High blood cholesterol

1. How long have you had high blood sugar? *

2. What is your fasting blood sugar test range when using a home glucose monitor? *

3. Is there a family history of diabetes? (if “yes”, provide details) *

Yes No

Details

4. Do you have increased thirst? (if “yes”, provide details) *

Yes No

Details

5. Do you have increased hunger? (if “yes”, provide details) *

Yes No

Details

6. Do you have frequent urination (especially at night?) (if “yes”, provide details) *

Yes No

Details

7. Have you noticed unexplained weight loss? (if “yes”, provide details) *

Yes No

Details

8. Do you have frequent fatigue? (if “yes”, provide details) *

Yes No

Details

9. Do you have recurrent vaginitis?（for female）(if “yes”, provide details)

Yes No

Details

10. Do you have difficulty with erections (for male) (if “yes”, provide details)

Yes No

Details

11. Do you have blurred vision? (if “yes”, provide details) *

Yes No

Details

12. Do you have tingling or numbness in your hands or feet? (if “yes”, provide details) *

Yes No

Details

13. Do you have slow-healing wounds? (if “yes”, provide details) *

Yes No

Details

14. Please list all medications, or supplements (including vitamins) you are currently taking. *

1. How long have you had high blood pressure? *

2. When is your daily blood pressure higher? *

Morning Afternoon Evening

3. Is there a family history of high blood pressure, heart attack, or stroke? (if “yes”, provide details) *

Yes No

Details

4. Do you have an inactive lifestyle? (if “yes”, provide details) *

Yes No

Details

5. How much alcohol (beer, wine, liquor) do you consume on an average day? *

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day

6. How often do you add salt to your food? *

Almost never Sometimes Frequently Never

7. Do you use any of these medications: birth control pills, steroids, decongestants, and anti-inflammatories? (if "yes", provide details) *

Yes No

Details

8. Do you have frequent blurred vision? (if "yes", provide details) *

Yes No

Details

9. Do you have frequent tinnitus (ringing of the ears) (if "yes", provide details) *

Yes No

Details

10. Do you have frequent dizziness and or headache? (if "yes", provide details) *

Yes No

Details

11. Do you have any edema in your feet or legs, or puffy eyelids in the morning? (if "yes", provide details) *

Yes No

Details

12. Do you have a bad temper, or are easily irritated or angered? (if "yes", provide details) *

Yes No

Details

13. Please list all medications, or supplements (including vitamins) you are currently taking. *

1. How long have you had high blood cholesterol? *

2. Do you have a family history of high blood cholesterol? *

Yes No

Details

3. What are the results of your HDL and LDL blood tests? *

4. Do you have an inactive lifestyle? (if “yes”, provide details) *

Yes No

Details

5. How much alcohol (beer, wine, liquor) do you consume on an average day? *

I don't drink 1-2 glasses/day 3-4 glasses/day 5+ glasses/day

6. How often do you add salt to your food? *

Almost never Sometimes Frequently Never

7. Do you always feel tired or fatigued? (if "yes", provide details) *

Yes No

Details

8. Are you frequently drowsy or dizzy? (if "yes", provide details) *

Yes No

Details

9. Do you have excess phlegm or mucous? (if "yes", provide details) *

Yes No

Details

10. Do you have fatty liver? (if "yes", provide details) *

Yes No

Details

11. Do you have diabetes and or high blood pressure? (if "yes", provide details) *

Yes No

Details

12. Please list all medications, or supplements (including vitamins) you are currently taking. *

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

Browse Files

Signature *

Clear

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

Common Questions