traditional chinese medicine
808-652-0381

Intake Form

If you want to give me a head start on helping you, please fill out the intake form and hit “submit” at the bottom. Mahalo!

New Patient Form

Name
address
phone
email
occupation
date of birth/ Age
physician name
height
weight
female
male
single
married
please check any medical history that applies   Asthma
  Alcohol or drug abuse
  Cancer
  Diabetes
  High blood pressure/ Cholesterol
  Heart Disease
  Hepatitis
  HIV/ AIDS
  Mental disorder/ Emotional Trauma
  Multiple Sclerosis
  Stomach Ulcers
  Stroke
  Thyroid Discorder
do you smoke, If so how often
Please list any drugs, herbs or supllements that you have taken within the last three months
Please rate your daily stress level on a scale of 1 being the least stress to 10 being the worst stress
Please rate your energy level on a scale of 1 being the least energy to 10 being the most energy
List any problems you may experience with sleep, insomnia, nightmares
Please list any problems with digestion, bowels, or urination
Please list any issues with ears, eyes, mouth, throat, sinuses
Please list any problems with skin or allergies
Do you experience headaches or dizziness, how often?
Any issues around Menses, menopause or libido
Any outstanding emotions, or problems with handling stress?
Please describe any pain, cardio problems, or circulation issues
not a robot!