Online Diagnosis Form

Thank you for taking the time to complete this form. Please fill out to the best of your ability. If there are some questions you cannot answer, simply write "Unable to answer," no worries.

First Name *

Last Name *

Email *

Date of birth(birthday help us to know your health condition while you were born)

Phone *

Address

Country

State

Postal code

City

what is your major concerns?

Do you sweat at night while sleeping? If so, do you sweat just a little or do you sweat profusely? Where on your body do you experience sweating?

How is your bowel movement? Do you experience constipation? If so, how often do you have a bowel movement? Do you have pellet-like stools? Do you experience loose stools or diarrhea? If so, how often? Do you notice mucus or blood in your stool?

Do you experience frequent urination, urgency, or pain while urinating? Do you often have urinary tract infections (UTIs)? Do you experience nocturia? If so, how many times per night? Do you have difficulty urinating?"

Do you have hot flashes? How often?

Do you have headaches, nausea, acid reflux, belching, and abdominal pain? Do you have dizziness and heart palpitations?

Do you have lower back pain, leg pain, pain in the heels, or any joint pain? Neck and should pain? Do you have rheumatoid arthritis?

Do you experience emotions like depression, anxiety, sadness, or fear? Have you seen a Psychologist or Psychiatrist? Are you taking any psychiatric medication?

Do you have swollen lymph nodes? Do you have any other types of lumps or masses? Have you ever had cancer?

Do you have hemorrhoids? Are they swollen and painful? Are you experiencing any bleeding?

Do you have any skin conditions? Such as psoriasis, eczema, various rashes, or hives? Are they itchy? How long have you had them?

Do you typically feel cold? Are your limbs cold? Do you have Raynaud's phenomenon? Do you have any swelling? If so, where is the swelling located?

Do you have angina? Have you ever had a heart attack? Have you ever had a brain hemorrhage or stroke? Do you have hemiplegia? Do you have high blood pressure, diabetes, or high cholesterol?

Do you have any thyroid issues? Is it hypothyroidism or hyperthyroidism?

Do you have any sleep issues? Do you have trouble falling asleep or do you wake up easily? What time do you usually wake up?

Please list the Western medications you are taking, and indicate which condition each medication is helping you with.

Is your menstrual cycle regular? A cycle length of 23-35 days is considered normal. Is yours shorter or longer, or irregular? How many days do you bleed for? Do you experience excessive bleeding? Do you experience pain during menstruation, and do you pass blood clots? Do you experience mood changes before menstruation? Do you have uterine fibroids? Do you have ovarian cysts? Do you have fibrocystic breast changes?

Please upload a photo of your affected area.

Online Diagnostic fee *

CA$ 99

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