Patient Health Intake Form


In this form we will ask you a series of questions that will help us to acurate diagnose your condition, and to determine the best possible mix for the Personalized Herbal Tea Formula, made just for you. While some questions may not apply please be as thorough as possible in answering what is applicable. More information is better than less information.

Tip: Entries marked with the red asterisk

My Contact Information

So we can send you confirmation

In case we have questions

About Me

My Complaints I am here to resolve

This wizard helps you enter your health complains. But you don't have to use it. You can just record your free form comments in the space below.

Add to List

Your recorded complaints so far:

Let's review specific conditions

My Emotions. I might feel ...

Energy level I normally operate under ...

My Sleep Patterns

My Menstrual Cycle (Women)

My Menstrual Duration

My Menstrual Conditions

Emotions During Menstrual Cycle. I might feel ...

My Temperature

I Sweat

I have a Sensitivity or Allergic to:

My Appetite and Digestion

My Bowel Movement

My Body Weight

My Liquids Intake

My Urination

I Have Pain

Higher is Stronger

My Palms are moist

My Habits

I Exercise

My Medications


My Family History

Mother Side
Father Side

Informed Consent and Information Release Authorizaton

Please sign with your mouse or finger (touch screen)