1. Personal Information *

2. Purpose of Visit *

Please select your primary demands (multiple selections allowed) to help us match suitable medical resources for you.

General Health Check-upDental TreatmentPain ManagementGynecological TreatmentOphthalmology TreatmentOrthopedic TreatmentPediatric TreatmentGastroenterology TreatmentCardiovascular & Cerebrovascular TreatmentOncology Related TreatmentTraditional Chinese Medicine RehabilitationOther Requests
Other Requests Description:

3. Chief Complaint & Demands *

Please describe your symptoms, duration, previous diagnosis and treatment history in detail.

4. Medical History & Medication

Confirmed underlying diseases (multiple selections allowed):
HypertensionDiabetesHeart DiseaseHistory of TumorUterine Fibroids / Gynecological DiseasesThyroid DiseaseCerebral InfarctionLiver DiseaseKidney DiseaseNone of the above

Current long-term medications (Medicine name, dosage, administration cycle):

5. Allergies

No known drug or food allergies

6. Travel Medical Assessment *

This section helps evaluate your physical suitability for long-distance travel to China for medical treatment. Please fill truthfully.

1. Can you endure a long-haul flight of more than 4 hours?
Yes, no discomfortNeed wheelchair / oxygen supportUncertain, doctor assessment required
Special Assistance Requirements:

2. Abnormal physical conditions in the past month (multiple selections allowed)
No abnormalitiesFever over 38℃Severe pain (Score ≥7)Surgery within 2 weeksAcute myocardial infarction / cerebral infarction history
Other sudden physical conditions:

7. Imaging & Medical Records

Do you have access to the following documents? (multiple selections allowed)
Available CT / MRI / Ultrasound films or discsCan send electronic copies via email / cloud driveCan provide discharge summary / medical abstractNot ready yet, need assistance to arrange examinations

Have you received similar relevant treatment in other hospitals before?
NoYes, briefly state hospital, treatment plan and duration:

8. Special Requirements

No special requirementsNeeds for diet / religion / attendant / customized itinerary

9. Emergency Contact

10. Authorization & Consent

I confirm all information filled in this form is true and valid. I authorize our team to use the submitted personal information and medical records for medical matching, hospital appointment and medical coordination services. I understand all data will only be used for this medical service and will not be disclosed to unauthorized third parties.

I have fully read and understood the authorization terms, and agree to submit documents for medical coordination services