Online Patient Form

For on-line consultation, fill out the following form and we will contact you by e-mail. You may need to fill another set of questionnaires later. The outcome is typically a TCM diagnosis, herbal formula, and other recommendations. We will also supply herbs on request. 

Required (*)

1) Name: 
             
2) Sex: 
                 
3) Birth date:  
      
4) Occupation:   
  
(*) 5) Address:  
 
       
(*) 5-a) City: 

(*) 5-b) State: 

(*) 5-c) Zip Code: 

5-d) Country: 

                                      
(*) 6) Phone: 
             
(*) 7) E-mail:
             

8) General health (good/fair/poor/etc.): 

9) Brief description of your current condition:


10) Length of this illness:
 
11) Past ailments: 

12) Surgeries: 


13) Medication 1 and reason for taking: 

14) Medication 2 and reason for taking: 

15) Other medications: 

16) Diet (vegetarian, snacker, skipper, stuffer, etc): 

17) Pulse rate (per minute): 

18) Blood pressure (if known): 

19) Goal of treatment 

20) Diseases running in family: