Online Patient Consultation Form

Q1:Full name

Q2:Gender

Q3:Age / Date of birth

Q4:Nationality & country/city of residence

Q5:Phone number (with country code)

Q6:Please select your primary need:

Q7:Estimated treatment budget range

Q8:Please select your expected outcomes:

Q9:Primary area of discomfort

Q10:Specific symptoms (e.g. pain, numbness, dizziness, weakness, etc.)

Q11:Duration of symptoms

Q12:Symptom severity (pain scale 1–10, 1 = mild, 10 = unbearable)

Q13:Onset characteristics

Q14:Triggering factors

Q15:Impact on daily life / work

Q16:Previously diagnosed conditions

Q17:Past surgical history (please indicate date, procedure and hospital)

Q18:Drug / food allergy history

Q19:Chronic conditions (e.g. hypertension, diabetes, etc.)

Q20:Relevant examinations completed in your home country (e.g. CT, MRI, X-ray, blood tests, etc.)

Q21:Treatments received (e.g. medication, physical therapy, surgery, etc.)

Q22:Previous treatment effect & whether the condition has relapsed / worsened

Q23:Medical documents status

Q24:Expected date of arrival in China

Q25:Planned length of stay

Q26:Number of companions

Q27:You may select multiple options:

:I hereby confirm that all stated medical conditions and submitted medical documents are true and valid.I agree that the above information will be collected and used solely for hospital coordination and medical consultation, and will be kept strictly confidential.I understand that the initial online assessment does not constitute a final diagnosis. The specific treatment plan shall be subject to in-person consultation.