YWY Online Assessment

This is the most important health report form for you from the view

points of traditional Chinese medicine. Please read carefully and tick off the items correctly, so that our professional doctors could diagnose accurately and offer effective treatment for you.
The reason why you have to fill out this form seriously is that TCM is totally different than western medicine, and it emphasizes every exact individual symptom very much. Even for the same disease, there are many different reasons to cause it from person to person. Therefore the treatment is also different from person to person. Thanks for your understanding and cooperation.

All personal information you submit is encrypted and 100% secure.

Required*

*First Name
*Last Name
*Email
*Gender	Male Female
*Marital Status	Single Married
*Pregnant	Yes No
*Age
*Country
State
Postal Zip Code
*Address

*Telephone
Height Meters
Weight Kilograms
Disease History How Many Years
*What about your major complaints at present? Do you have the health problems of the heart and blood pressure? Serious or slight?

DETAILED SYMPTOMS ABOUT YOU.
Please choose appropriate so it will be easier for doctors to analyse.
Headache	Yes No
Loss of Hair
Blurred Vision	Yes No
Blood Shot Eyes	Yes No
Dizziness	Yes No
Tinnitus with noise of chirping of a cicada	Yes No
Reduced hearing abiilty	Yes No
Pale complexion	Yes No
Swollen and painful Nose	Yes No
Runny Nose	Yes No
Thin and white nasal discharge	Yes No
Thick and yellowish discharge	Yes No
Blockaded sense in the nose	Yes No
A bitter taste in the mouth	Yes No
Sour taste in the mouth	Yes No
Dry lips	Yes No


Slightly reddish tongue body	Yes No
Slightly whitish tongue body	Yes No
Deep-red tongue body	Yes No
Fissured tongue body	Yes No
Tooth-marks on the edges of the tongue	Yes No
I brush the tongue coating daily	Yes No
Tongue coating


Stiff neck	Yes No
Painful neck	Yes No
Itching throat	Yes No
Swollen and painful throat	Yes No
Frequent throat inflammation	Yes No
Spit thin and white phlegm	Yes No
Dry throat	Yes No
Spit thick and yellowish phlegm	Yes No


Chest oppression	Yes No
Difficulty in Breathing
Having middle degree problem of the blood pressure	Yes No
Slight palpitations	Yes No
Severe palpitations	Yes No
Stabbing pains in the heart	Yes No
Distention and discomfort of the right rib-side	Yes No
Having slight heart problem	Yes No
Having middle degree problem of the heart	Yes No
Having severe heart problem	Yes No
Having slight problem of the blood pressure	Yes No
Having severe problem of the blood pressure	Yes No


Stomach pains	Yes No
Stomach distention	Yes No
Buming stomachache	Yes No
Cold stomachache	Yes No
Shrinking sense of the stomach	Yes No
Stomachache likes warmth or warm drinks	Yes No
Stomachache likes pressure on it	Yes No
Wish to vomit	Yes No
Dropping sense of the stomach	Yes No
Belch with sour taste in the mouth	Yes No


Lower abdomen pains	Yes No
Lower abdomen distention	Yes No
Lower abdominal pains like warmth and pressure	Yes No
Painful back with inability or difficulty to stretch or bend the back	Yes No
Aching pains of the shoulders and back	Yes No
Stiff and painful loins due to falling or sprain or hard physical work	Yes No
Dull pains of the loins	Yes No
Left kidney area pains	Yes No
Right kidney area pains	Yes No
Cold sense on the back	Yes No


Stiff four limbs	Yes No
General body pains	Yes No
Muscle spasm of the body	Yes No


Tight or spasmodic tendons of the general body	Yes No
Running pains of the body joints	Yes No
Heavy sense wrapping the body	Yes No
Swollen and painful joints of the arms	Yes No
Swollen and painful joints of the legs	Yes No
Edema of the lower limbs	Yes No
Edema of the general body	Yes No
Numbness of the four limbs	Yes No
Aversion to cold and cold limbs	Yes No
Hot sense in the soles and palms in the afternoon or night often	Yes No


Day time sweat	Yes No
Sweat at night	Yes No
Insomnia	Yes No
Dreaminess	Yes No
Frequent waking up during sleep	Yes No


Thirst and like drinks	Yes No
Like cold drinks	Yes No
Like hot drinks	Yes No
Eat much cold foods	Yes No
Easy hunger and excessive food-intake	Yes No
Hunger without desire to eat	Yes No
Reduced appetite	Yes No
Eat much fast foods	Yes No
Irregular food intake	Yes No


Frequent daytime urination	Yes No
Urgency in urination	Yes No
Color of urine
Painful urination	Yes No
Frequent night urination	Yes No
Dribbling urine after urination	Yes No


Constipation	Yes No
Diarrhea with burning sense at the anus	Yes No
Diarrhea with clear undigested foods	Yes No
Diarrhea worsened by emotional frustration or distress	Yes No
Diarrhea around 5 O'clock (AM) every day with abdominal pains	Yes No
Thanks so much for your patience that you are still working carefully on this form.

MALES PLEASE TAKE SOME TIME TO COMPLETE THE FOLLOWING QUESTIONS.
FEMALES PLEASE SCROLL DOWN TO FEMALE RELEVANT SECTION.
Reduced sexual ability	Yes No
Impotence	Yes No
Premature ejaculation	Yes No
Weak erection	Yes No
Seminal emission in the daytime	Yes No
Reduced desire of sex	Yes No
Masturbation Frequency
Testicle pains one side	Yes No
Testicle pains two sides	Yes No
Swollen scrotum	Yes No
Cold damp scrotum	Yes No
Itching scrotum	Yes No
Damp heat scrotum	Yes No
Private part with strong smell	Yes No
Pains of the perineum	Yes No
Buming sense in the urethra	Yes No
Excretion from the opening of the urethra	Yes No
Dropping sense of the anus	Yes No
Too strong sexual desire	Yes No
Sterility	Yes No


FEMALES PLEASE TAKE SOME TIME TO COMPLETE THE FOLLOWING QUESTIONS.
Sexual desire
Menstruation
Amount of menstrual blood
Buming sense in the womb	Yes No
The womb like warmth and pressure	Yes No
Cold sense in the womb	Yes No
Color of the menstrual blood
Menstrual blood clots	Yes No
Profuse and sudden uterine bleeding	Yes No
Gradual uterine bleeding	Yes No
Amenorrhea (stop of menstruation)	Yes No
Profuse and thin leucorrhoea	Yes No
Profuse, thick and yellow leucorrhoea	Yes No
Infertility	Yes No


Wrist Pulse Both Male & Female:
Powerful pulse	Yes No
Weak pulse	Yes No
Wrist Beats Per Minute
Thin pulse body like a thread	Yes No
Deep pulse	Yes No
String-like pulse (touching the wrist pulse like touching a tight string of a musical instrument)	Yes No
Abnormal rhythm of pulse	Yes No


Living Environment:
Always a cold and windy living environment	Yes No
Damp living environment	Yes No
Dry living environment	Yes No


Temperament and Emotions:
Optimistic, open-minded and happy	Yes No
Pessimistic	Yes No
Melancholic	Yes No
Always worrisome	Yes No
Nervous often	Yes No
Over thinking often	Yes No
Lone and close-minded	Yes No
Easy to be angry always	Yes No
Depressed often	Yes No
Irritability often	Yes No


Spirit and work
Fatigued	Yes No
Stressful work	Yes No
Too much stressful work	Yes No

What kind of foods do you like? What are your daily foods? Do you smoke? What are your private hobby? Do your family members suffer the similar health problems?

What about current or past prescribed medications, and their effects? Any past hospitalizations for this or other diseases? Do you suffer from other internal diseases? If you do, please describe the degree of seriousness.


Do you wish to come to our Clinic to our for better assistance?
Let us know the approximate date & time of arrival
Please seek an official invitation letter from us now so that you could get a three months visa
The first choice is the prepared herbal products produced by hundreds different herbal companies in Hong Kong and GMP certified companies in China. We have four hundreds different perfect herbal products for various commonly encountered diseases.
The second choice is raw herb tea. We could prescribe a special herbal formula for you, then mix the raw herbs. Please decoct the raw herbs to make herbal tea, drink the tea twice a day. The adult dosage is 200 milliliters each time. The first treatment course will be 20 days. We will air ship to you. The general cost for 20 days supply will be US$220.00 for you.
The third choice is herbal granule. We could prescribe a special herbal formula for you. The herbal granule is dissoluble and concentrated made through modern technology. Each dosage is composed of different sachets of granule. Please cut every sachet and put the granule into a cup. Put a little hot water into the cup and stir the herbal granule. For adule, after that please put another 250ml boiling water into the cup and stir it with spoon. You will get some liquid, drink it when it is cool or still warm. Please drink half of the liquid in the morning and another half of that in the afternoon. The general cost for 20 days will be US$200.00 for you.
The fourth choice is honey herb pills. We could make the herbal powder into honey herb candies for you. You could first order 20 days supply as the first treatment course. It is about 200 pills for you, about 10 grams each pill. The adult dosage is 3 to 4 pills each time, three times a day. We will air ship the package to you. The general cost for 20 days will be US$200.00 for you.
*The above prices are estimation, only our RCMP will provide you with the right formulas & pricing according to your requirements
Before submitting your form, please check if you have correctly filled out your email address. Thanks.

HEALTH ADVISORY: The statements made have not been evaluated by the Food & Drug Administration. Herbal formulas, natural remedies, and aromatherapy products related to alternative health products on this site have not been evaluated by the U.S. FDA. Our products are not intended to diagnose, treat, cure or prevent any disease. The statements on this website are based principally on traditional knowledge accumulated over thousands of years of Chinese medical practices. The content provided is for educational purposes only and is not intended as a substitute for advice from your health care professional. You should not use the information on this site to diagnose or treat any health issues. As always, you should consult with a healthcare professional before starting any diet, beginning an exercise program, using herbs or other supplementation programs, before taking any pharmaceutical medication, or if you have or suspect you might have a health problem. Unless specifically mentioned in the product label, our herbal supplements, natural remedies, and alternative health products are not intended for children under the age of 18, pregnant women, or nursing mothers. Ingredients and dosage recommendations may change - see product label for current information.