Online Patient Consultation Form

This form is designed to learn about your health condition and medical needs. All information provided will be kept strictly confidential and used solely for medical consultation purposes.
*1. Full name
2. Gender
3. Age / Date of birth
4. Nationality & country/city of residence
*5. Phone number (with country code)
6. Please select your primary need:
7. Estimated treatment budget range
8. Please select your expected outcomes:
Confirm diagnosis
Undergo surgical treatment
Conservative treatment / medication plan
Functional rehabilitation and recovery
9. Primary area of discomfort
10. Specific symptoms (e.g. pain, numbness, dizziness, weakness, etc.)
11. Duration of symptoms
12. Symptom severity (pain scale 1–10, 1 = mild, 10 = unbearable)
13. Onset characteristics
Persistent
Intermittent
Worse at night
Worse with activity
Other
14. Triggering factors
15. Impact on daily life / work
16. Previously diagnosed conditions
17. Past surgical history (please indicate date, procedure and hospital)
18. Drug / food allergy history
19. Chronic conditions (e.g. hypertension, diabetes, etc.)
20. Relevant examinations completed in your home country (e.g. CT, MRI, X-ray, blood tests, etc.)
21. Treatments received (e.g. medication, physical therapy, surgery, etc.)
22. Previous treatment effect & whether the condition has relapsed / worsened
23. Medical documents status
24. Expected date of arrival in China
Please select
25. Planned length of stay
26. Number of companions
27. You may select multiple options:
Flight booking assistance
Airport pick-up and drop-off service
Hotel reservation assistance
Full-time interpretation accompaniment
Special dietary requirements (e.g. vegetarian, halal, etc.)
Other needs
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.