Questionnaire about Hives


Online Email Consultation: In order for Dr. Li to have a clear picture of your situation, please fill out the short questionnaire below. If possible, attach photo(s) of the affected area at the bottom of this form. After you have submitted the form, you will receive a confirmation that your form was processed. The form will be sent directly to Dr. Li for her review. Please allow 1-2 business days for a response. **

Your name:

Patient Name (if different)

 

Your Email Address:

 

Verify Email Address:

Cell Phone Number (Optional):

Sex:

Female Male

Age:

Race:

Weight:

(pounds)

Occupation:

How long have you had Hives?

Less than 1 month      Less than 1 year      1 to 5 years     over 5 years

Which part of your body does the hives affect?

Arms  Legs  Trunk  Scalp  Palm  Sole 

What type of Hives do you have?

Urticaria  Angioedema

Do you have any food allergy?

Dairy Products  Seafood  Gluten  Soy  Nuts  citrus Fruit  Other

What symptom of Hives do you experience?

Red Bumps(wheals)  Pale Bump(wheals)  Itchiness  Swelling

How Serious do you think your hives is?

Mild  Moderate  Severe

Have  you been taking any anti-histamine?

Yes,  what kind?
No

What time of the day do your hives come out?

Morning  Afternoon  Evening  Night

How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)

Please add any comments and questions you have below:

You may attach (optional) Pictures to help Dr. Li understand the situation:

Image1:

Image2:

Any personal information you submit to us is strictly confidential. Please take a look at our privacy policy to learn more


**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.