May we send you a DM from our clinic ?
Q1: Please describe your current health problem.
Q2: Touch where you feel pain , ache , etc...
Q3: When it began?
Q4: How it began?
Q4-1: If "injury" or/and "illness" or/and "other", please describe details.
Q5: How often your symptoms present?
Q6: Have you been given a diagnosis for this problem?
Q6-1: If "yes", what is the diagnosis?
Q7: If your problem is pain , what kind of pain this?
Q8: Severity of the condition
Q9: Are you currently taking αny medication?
Q10-1: If "Yes", please list your medication below.
Q10: Do you have any prothesis in your body?
Q11: Your past medical history. Check any of the following conditions you currently have , or have had in the past.
Q11-1: Have you ever hαd any surgery ?
Q11-2-1: If "Yes" , Why and when?
Q12: Please check all current symptoms.
Q12-1: If "Swelling", which part of body do you have it?
Q12-2: If "Muscle Pain", which part of body do you have it?
Q12-3: If "Joint Pain", which part of body do you have it?
Q12-4: If "Sprain", which part of body do you have it?
Q12-5: If "Numbness", which part of body do you have it?
Q12-6: If "Neuralgia", which part of body do you have it?
Q12-7: If "Other", please describe the details.
Q13 : Please tell us about your lifestyle
Q13-1: How many days a week do you drink alcohol?
Q13-2: Do you smoke？
Q13-2-1: If "Yes", How many cigarette a day do you smoke?
Q13-3: How many cups of tea/coffee a day do you drink?
Q13-4: How long do you sleep? ( ex. XX hours )
Q13-5: Have you gained/lost weight recently?
If you have gained/lost your weight recently, how many pound in how many months/years was it?
Please select all that apply
※ We will use this information when deciding on a treatment method. Thank you for your cooperation.
Q15: your hand
Q16: your feet
Q18: When you have fever
Q19: urine volume
Q20: urine color
Q21: stool frequency
Q22: stool condition
Q25: Night sweat
Q27: Your physical problems are reduced when you have do activity
Q28: Your physical problems are got worse when you are tired
Q29: The condition of the day
Q30: You body
Q39: Your hand and foot feel hot
【For woman only】
Q40: Menstrual Cycle
Q41: Menstrual period
Q42: Menstrual bleeding
Q43: Menstrual blood color
Q44: Period of menstrual pain
Q45 Are you pregnant ?
Q45-1: If "Yes", how many weeks pregnant are you?
Q46 Are you breastfeeding?
＊Please fill out the below.＊
Q1: How did you know about our clinic?
Q1-1: If "Internet", Please choose form which media?
Q1-2: If "Family or Friend", Please write down your family or friend's name.
Q1-3: If "Flyer", please choose which flyer?
Q1-4: If "Magazine", Please write down the name of a magazine
Q2: What are you expecting from today's treatment？
Q2-1: If "Other", please describe the details.
＊Thank you for your cooperation!＊