Insomnia Consultation

Full Name *

Contact Email *

Your Main Concern

If other, Please mention your cause of concern

Please provide more details(Fertility Support)

Please provide more details(Stress, anxiety, or depression)

Please provide more details(PCOS)

Please provide more details(Menopause Symptoms)

Please provide more details(Weight Management)

Please provide more details(Digestive Health)

Please provide more details (If you need fertility support, please select Fertility as your main concern)

Please provide more details(Sleep Issue)

Light sleep, waking tired or low energy

Fatigue or Poor Concentration

Menopause (e.g. Hot Flush, Night sweating)

PMS (e.g. Before periods come, poor sleeping)

Stress (Irritability, Mood Swing, Headaches)

Panic Attack / Palpitations

Unexplained

OtherOther

Please provide more details(Skin & Hair)

Acne

Alopecia (e.g. Hair thinning, patchy hair loss)

Eczema (e.g. Dry, itchy, or inflamed skin patches)

Hair Loss

Psoriasis (e.g. Dry, scaly, or red skin patches)

Aging Related (e.g. dryness, irritation, itchy)

OtherOther

Please provide more details(Pain Management)

Please provide more details(General Issue)

Contact Number - please include your country code

Your WhatsApp number include country code

Country of Residence

Occupation *

Are you based in London, If yes , Would you like to book clinic consultation for you?

Date of Birth

Weight in KG *

Height In CM *

How long have you trying to conceive?

Would you like to provide details about your period? (For more accurate diagnosis)

Yes

No

How frequently do your periods come? (Last 3 month period.)

How long do your periods last?

How would you describe the amount of your periods?

Heavy

Normal

Light

OtherOther

What is the colour of your period?

Do you have blood clots during your period?

Yes

No

OtherOther

Do you have white discharge between periods?

Yes

No

If yes, what is the nature?

Watery

Sticky

Other

Do you experience cramping with your periods?

Yes

No

If yes, when during your cycles do you have pain (check all that apply)

Before

During

After

How would you describe the cramps?

Mild

Moderate

Severe

Do you bleed or spot between periods?

Yes

No

Do you have other symptoms with your periods? Or general? *

If any applies, when during your cycles do you have these symptoms (check all that apply)

Before

During

After

Have you ever had any of the following infections involving any part of the reproductive system?

If you had any treatment for these, when? (leave blank if you did not)

Have you ever used contraception in the past?

Yes

No

If yes, which type of contraception ?

How long have you and your partner been attempting to achieve pregnancy?

Have you been treated for infertility previously?

Yes

No

What was the cause of infertility?

Have you ever attempted in vitro fertilization (IVF)?

Yes

No

If yes, please specify

Have you had a miscarriage before?

Yes

No

Please give details of the miscarriage.

Do you have other fertility issues?

Endometriosis

Cyst

Fallopian Tube blocked

Overweight

Did you have surgery on these?

If you had surgery, please give more details

Medical history - do you have the following conditions?

High Blood Pressure

High Cholesterol

Diabetes

Allergies

Medical history - do you have the following conditions?

High Blood Pressure

Diabetes

Allergies

How much water/liquid do you drink daily?

< 1 litre

1-1.5 litre

1.5-2 litre

> 2 litre

Do you consume meat or follow a vegetarian/vegan diet?

Omnivore (Eats Meat & Plant-Based Foods)

Vegetarian

Vegan

Where did you hear about us? Where did you hear about us?

I would like to receive email updates from TCM blog by GinSen

Yes

No

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I can confirm I have read the terms and conditions *

Yes

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