Oriental Wellness Medical Group Inc
10301 S De Anza Blvd #2, Cupertino, CA 95014
orientalwellnessmedical@gmail.com
669-400-7828
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Name(姓名)
*
Phone(电话)
Email
Age Group(年龄段)
*
--- Select Choice ---
Under 18(18以下)
18–25
26–35
36–45
46–55
56+
Gender(性别)
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--- Select Choice ---
Male/男
Female/女
Other/其它
Confidential/不便说明
Main concerns(主要困扰)
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Sleep｜睡眠
Spleen & stomach (bloating/acid reflux/appetite)｜脾胃（胀 / 反酸 / 食欲）
Constipation /diarrhea｜便秘 / 腹泻
Dry mouth /bitter mouth｜口干口苦
Fatigue /weakness｜疲劳乏力
Emotional stress｜情绪压力
Skin problems｜皮肤问题
Pain (shoulder, neck, waist)｜疼痛（肩颈腰）
Gynecology (menstruation/preparation for pregnancy)｜妇科（月经 / 备孕）
Other｜其他
Main Medicine tendency(冷热倾向)
Cold & heat tendency(冷热倾向)
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--- Select Choice ---
Fear of cold｜怕冷
Fear of heat｜怕热
No obvious preference｜冷热都不明显
Cold hands and feet｜手脚冰凉
Duration(持续时间)
*
--- Select Choice ---
< 2 weeks｜<2 周
2 weeks – 3 months｜2 周–3 个月
3 – 12 months｜3–12 个月
More than 1 year｜1 年以上
Bowel condition(大便情况)
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--- Select Choice ---
Formed, once daily｜成形每日 1 次
Constipation (once every 2+ days or incomplete evacuation)｜便秘（2 天 + 一次或排不尽）
Loose stool /diarrhea｜偏稀腹泻
Sticky and difficult to pass｜黏腻不爽
Other｜其他
Thirst condition(口渴情况)
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--- Select Choice ---
Not very thirsty｜不太渴
Thirsty but satisfied with a little｜渴但喝一点就够
Very thirsty, prefer cold drinks｜很渴爱冷饮
Dry mouth at night｜夜里口干
Current condition(目前状态)
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--- Select Choice ---
Menstruating｜经期中
Not menstruating｜非经期
Trying to conceive｜备孕中
Pregnancy｜孕期
Postpartum breastfeeding｜产后哺乳
Menopause｜更年期
For female only(女性填写)
Sleep condition(睡眠情况)
*
--- Select Choice ---
Difficulty falling asleep｜入睡难
Easy to wake, frequent dreams｜易醒多梦
Early awakening｜早醒
Acceptable｜还可以
Upload tongue photos (multiple allowed)｜上传舌头照片（可多张）
Drag & Drop Files,
Choose Files to Upload
You can upload up to 5 files.
Tips(拍照提示)：Natural light / white light; no filter; tongue relaxed and naturally extended; clear focus; try to capture the root of the tongue as much as possible.(自然光 / 白光；无滤镜；舌头放松自然伸出；对焦清晰；尽量拍到舌根。)
Currently taking any medicine or supplements?(目前是否在服药 / 保健品)
*
--- Select Choice ---
Yes | 是
No | 否
Medicine Name(药品名称)
If you are taking medication, please fill in; if not, please ignore.
Additional Notes(补充说明)
(e.g.: Severe internal heat recently / constant bloating / high stress / easy sweating) | 例如：最近特别上火 / 总是胃胀 / 压力大 / 容易出汗等）
Submit(提交)
Address/地址
10301 S De Anza Blvd #2, Cupertino, CA 95014
Contact info/联系方式
orientalwellnessmedical@gmail.com
669-400-7828
Wechat/微信
