Health QuestionnaireSo we can tailor the herbs specifically for you!All information you provide will be kept strictly confidential. Name * First Name Last Name Best email to contact you: * Age * Gender * Male Female Height * Weight (lbs) * General Health Information: Please provide as much as you can Main current symptoms: Any Allergies: Sensitivity to Cold or Heat: Spontaneous Sweating or Night Sweating: Dry Mouth / Thirstiness / Bitter Taste in Mouth: Insomnia / Vivid Dreams / Mental State / Easily Fatigue: Stomach Pain / Acid Reflux / Stomach Bloating: Appetite / Eating Habits: Stool (Diarrhea / Loose / Normal / Constipation): Urination (Color): Diabetes (Yes / No): High Blood Pressure (Yes / No): Heaviness / Fatigue in Limbs or Weakness / Soreness in Lower Back and Knees: Menstrual Information (For female patients): Delayed or Early Menstruation: Menstrual Pain / Flow Amount / Blood Color: Submitted Successfully! Thank you!
