Questionnaire about Shingles

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):


Female Male






How long have you had Shingles?

Less than 1 Month      1 to 3 months     3 to 6 months     over 6 months

Do you have chickenpox in your young age?

Yes  No 

Which part of your body does the Shingles affect?

Face or Head  Chest or Upper Back  Leg or Lower Back  Leg 

What symptom of Shingles do you experience?

Skin Rashes Blisters Itching Burning Pain Fever

How Do you rate your pain?

0 1 2 3 4 5 6 7 8 9 10
| |   | |   | |     |
None   Mild     Moderate     Servere    

None   Mild   Moderate  Severe  

What type of treatment have you used before?

Topical.                   what kind?
Oral Medication.       what kind?

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:



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.