Physiciansherbalformula 3030 west olympic blvd. #220 L A, CA 90006
(213) 738-7788 Answering Hours: Mon to Thurs 9 AM to 4 Pm, Fri 9 AM to 1 pm
One may answer some of the questions to the below questionaire to receive a suggestion as to the appropriate formula for your chief symptom. E mail to shinsmed@gmail. com
One may also visit our medical clinic website www.naturalherbalalternative.com
THE QUESTIONAIRE FOR CUSTOM MADE HERBAL FORMULA
Basic Demographic: Age: Sex:
Type of Residence: Type of work:
Any particulars worth mentioning:
HISTORY OF PRESENT SYMPTOM:
What is the Chief Symptom? How long has been the duration of it?
When is the symptom? In the morning in the afternoon in the evening
at night Any particular environment or season?
How long does the symptom last? and how often is it?
How severe is the symptom? Please Grade it (from 1 to 10):
What factors make the symptom worse?
What factors alleviate the symptom?
Are there any associated symptoms or physical signs?
Have you been evaluated for the chief symptom by a medical doctor?
What were the diagnosis and what treatments or medications were prescribed? What has been the response to treatment?
PAST MEDICAL HISTORY:
Hypertension: Diabetes mellitus: High Cholesterol:
Head and Neck Disease: Heart Disease:
Lung Disease: Gastrointestinal/Liver Disease:
Genitourinary Disease: Musculoskeletal Disease:
Neuropsychiatric Disease: Endocrine Disease:
REVIEW OF SYMPTOMS ( please list all other major symptoms whether or not they seem related to the chief symptom ):
ANY PHYSICAL SIGNS YOU HAVE OR YOUR MEDICAL DOCTOR HAS INFORMED YOU:
ANY SIGNIFICANT LAB OR RADIOLOGICAL ABNORMALITIES:
YOU CAN E MAIL THE PICTURES OF YOUR FACE AND TONGUE, IF YOU WISH.
Physicians Herbal Formula