1. It is helpful to fill the blanks according to your own state for the correct diagnosis.
2. We will contact you by the E-mail or telephone if your condition is complex, so please write an effective  E-mail address or a phone number.
3. Fill the words, numbers or¡°¡Ì¡± into the blanks according to your disease history.
4. We will read your letter and write to you as soon as possible.  

 
Name: *   Gender:     Age:      Marriage:    
Occupation:
E-mail: *
Telephone Number:

 Blanks
1.The Symptoms£º
 1 Course of The Disease Year(s) and/or  Month(s)  £¨The Duration of Constipation£© 
 2 Frequence of Defecation    Times/Day
 3 Desire to Defecate Scarcely        Sometimes           Normal       Frequent            
 4 Senses of Defecation
Unfinished Feeling Force to defecate  Blocked  Distented of Perineum
Sense of falling  Tightened anus  Painful  Lump of anus
 5 Process of Defecation Average Time£º   Min./Time    
Smoothly   Delayed    Finger Help   Undefecated 
 6 Characteristics of the Stool Weight: g/Time  Diarrhea Stool Soft Stool
Hard Stool Blood Stool Mucous Stool
 7 Restrain of Defecation Scarcely        Sometimes                Frequent     
2.Other symptoms:
 1 Abdominal Pain or Distention
Pre-defecation    Defecating  Post-defecation  Paroxysmal  
Lasting        Fit Regularly:  Yes        No  
 2 Diet
Weight: g/Day Amount of Drinking: ml/Day
Vegetarian Diet     Balanced    Regular Diet:  Yes No  
 3 Other Diseases
Hyperthyroidism Hypothyroidism Hypertension Diabetes Mellitus
Adiposity Hysteromyoma   Trauma of Lumbar  Vertebrae

3. Disease History: ( For example: the testing report or the medicine which you had taken.)  

4.Your Problems or Advice: