(Follow Up Use only)
In-Depth Health Evaluation from the Perspective of Traditional Chinese Medicine (TCM)
for a minimal fee by a licensed acupuncturist professionally trained in TCM.

Here is how it works.
1. Fill in and submit the followup evaluation form below.
2. Pay $35 consultation fee, it is good toward 3 followup consultations.
3. Our licensed TCM doctor will evaluate your progress in combination with your previous evaluation.
4. We will notify you within 1-5 days the evaluation result and recommend any herbal remedy as needed.
5. You may purchase the remedies from us or other sources at your discretion.

For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

What changes in your main concern have you had since your last consultation?

Have you seen a physician for the condition since your last consultation? What is the diagnosis?

What medicine or treatment has your physician prescribed for the condition? How long have you used? How well do you respond to it?

Did you see other Chinese herbal doctors or acupuncturists for the condition since your last consultation? What is the diagnosis or prescription?

Have you taken the herbal remedy we prescribed for you? What are the dosage and for how long?

Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Fever: yes no.
Persistent low fever: yes no.
Heat intolerance: yes no.
Cold limbs: yes no.
Cold fingers/feet: yes no.
Cold back: yes no.
Chilly sensation: yes no.
Warm and moist palms/sole: yes no.
Warm and moist skin: yes no.
Spontaneous perspiration: yes no.
Night sweat: yes no.

Pale face: yes no.
Flushed face: yes no.
Fatigue: yes no.
Lassitude: yes no.
Weak voice: yes no.
Lack of interest in talking: yes no.
Short of breath: yes no.
Weak pulse: yes no.

Headaches: yes no.
Migraine headaches (one side): yes no.
Tension headaches: yes no.
Cluster headaches: yes no.
Dizziness: yes no.
Spinning: yes no.
Tinnitus (ring in the ears): yes no.
Blurred vision: yes no.
Red eye: yes no.
Eye pain: yes no.
Hair loss: yes no.
Hair graying: yes no.

Sore throat: yes no.
Difficult chewing or swallowing: yes no.
Dry mouth: yes no.
Thirst with desire for drinking: yes no.
Thirst without desire for drinking: yes no.
Bitter mouth: yes no.
Mouth odor: yes no.
Noticed difference in tongue color and coating from others: yes no.

Running Nose: yes no.
Stuffy Nose: yes no.
Cough: yes no.
Cough with little phlegm: yes no.
Cough with water phlegm: yes no.
Cough with yellow phlegm: yes no.
Cough with bloody phlegm: yes no.
Dry cough: yes no.
Wheezing: yes no.
Asthma: yes no.

Chest pain: yes no.
Abdominal pain: yes no.
Abdominal pain, relief with pressure: yes no.
Abdominal pain, worse with pressure: yes no.
Flank pain: yes no.
Shoulder pain: yes no.
Low back pain: yes no.
Low back weakness: yes no.
Arm pain: yes no.
Leg pain: yes no.
Arm/leg weakness: yes no.
Extremity numbness: yes no.
Leg pain while walking: yes no.
Joint pain: yes no.
Joint swelling: yes no.

Forgetfulness: yes no.
Emotional stress: yes no.
Mood swings: yes no.
Restlessness: yes no.
Depression: yes no.
Anxiety: yes no.
Irritability: yes no.
Mania: yes no.
Sleepiness: yes no.
Difficulty falling asleep: yes no.
Difficulty staying asleep: yes no.
Frequent awakenings: yes no.
Insomnia: yes no.
Dreamfulness: yes no.
Palpitation: yes no.
Angina: yes no.

Recent weight gain: yes no.
Recent weight loss: yes no.
Edema: yes no.
Poor appetite: yes no.
Nausea: yes no.
Vomiting: yes no.
Bloating: yes no.
Abdominal distention: yes no.
Indigestion: yes no.
Heartburn: yes no.
Stomachache: yes no.
Change in bowl habits: yes no.
Dry stool: yes no.
Loose stool: yes no.
Bloody stool: yes no.
Diarrhea: yes no.
Constipation: yes no.
Anal burning: yes no.

Frequent urination: yes no.
Urinary urgency: yes no.
Urinary pain: yes no.
Urinary dripping: yes no.
Urinary difficulty: yes no.

Women only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Pain in menstruation: yes no.
Menstruation disorders: yes no.
Menstruation irregularity: yes no.
Bleeding between periods: yes no.
Bleeding after menopause: yes no.
Hot flash: yes no.
Breast distention: yes no.
In pregnancy: yes no.
In lactation: yes no.

Men only--Do you have any of the following? If yes is chosen, please specify how long, how often, or how severe you have it.
Premature ejaculation: yes no.
Weak erection: yes no.
Impotence: yes no.
Excessive sexual drive: yes no.
Loss of sexual drive: yes no.
Emission: yes no.
Active sexual life: yes no. How often:
Masturbation: yes no. How often:

A photo of your face and of your tongue would be helpful in TCM evaluation. Can you provide them by emailing to consult@activeherb.com? yes no.

Do you have other comments on your health?

Please scroll up to the top and double check what you have completed and correct any error before submission

(You may alternatively print out the form and mail it to us along with the payment of $35.)

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ActiveHerb Technology, Inc., 10855 Sorrento Valley Road, Suite 204, San Diego, CA 92121