EmailMeForm
ZHANG CLINIC Follow-up Consult Form
Name
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First
Last
Phone
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Email
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Follow-up
Please answer these questions to the best of your abilities. We will then contact you by email or phone for discussion
Please briefly describe the main issue.
For example: back pains, headaches, night sweats, etc)
Please rate the severity of this issue.
 
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Approximately when did you first notice the onset of this issue?
(If possible, please specify a date and time )
How often does this issue occur in one day?
Does this issue keep you from sleeping or wake you up? If yes, in what way?
Does this issue affect your daily activities? If yes, in what way?
Is there anything that makes this issue worse or better? (For example: heat makes the pain better, cold makes the pain worse, etc )
Is there a particular time of day when this issue is worse or better? (For example: worse after meals or better after bowel movements)
Please list any other symptoms that you feel is related to the main issue
(I.E. nausea, vomiting, fatigue, poor appetite, coughing, acid reflux, dizziness, blurred vision, heaviness sensation, extreme thirsty, stuffy chest, vertigo, knee & back soreness, weak knees/legs, tinnitus, insomnia, palpitation, restlessness, irritability, chills, fever, both chills and fever, sweating, weak voice/hard to speak, cold/hot hand/feet, bitter taste in mouth, constipation, diarrhea, shortness of breath, loose stool, feverish feeling in the afternoon, hollow sensation inside the head, irregular heart beat, diabetic/unstable blood sugar levels)
If the main issue is related to a type of pain, please complete the additional fields below. Otherwise, skip to the end of the form and press the submit button.
Please describe the location of the pain
(For example: Top of the head, left knee, wrist etc)
Please describe the nature of the pain
(For example: dull, sharp, throbbing, constant, etc)
Does the pain move to different locations? If yes, from where to where?
Is there are redness, swelling or heat sensation at the site of the pain?
Are there any other symptoms associated with this pain (e.g. fatigue, nausea, dizzy, blurred vision, palpitation, sweating)?
Please list the medications you are currently taking:
Please list any surgical procedures or traumatic injuries you've experienced
Please include any additional notes you would like to add here
How is your current energy level?
 
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How is your current level of life stress?
 
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