• Patient Symptoms Questionnaires

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  • Date*
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    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • At first sight, I give the impression of being
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  • My overall facial outline is close to this shape:
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  • My face/head is characterized by
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  • On a cursory look at my eyes and eyebrows,
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  • On a cursory look at my nose,
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  • On a cursory look at my mouth and chin,
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  • On a cursory look at my ears,
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  • When I am speaking,
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  • Looking at my overall body frame, I am
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  • The part of my body that is the least developed is
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  • The part of my body that is the most developed is
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  • My shoulders are
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  • I have
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  • The part of the body that puts on especially more fat when I gain weight is
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  • Personality
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  • Digestion-Eating Habits
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  • Foods that don’t go down too well
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  • Digestive patterns
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  • Sleeping habits
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  • Stool
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  • Bowel habits
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  • The parts of my body that sweat the most are
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  • Sweating patterns
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  • Urinary habits
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  • Fatigue
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  • Frequently found symptoms
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  • Informed Consent Rule

    It is not medical diagnosis nor to treat specific disease. Herb formulas support to your body dysfuction. Is is not guranteed to treat medically. It helps patient's healing power, cirulation, and immune systems to improve your health conditions.

    I agree that above the statement.

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