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  • Heshoutang Diagnosis Form of Natural Health: Personal Information

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    Rost Yomboun
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    This document contains a diagnosis form for natural health that collects personal information such as name, address, email, phone number, occupation, sex, marital status, age, height and weight. It then asks questions to assess symptoms related to the spleen and stomach, such as appetite, stomach pain, bloating, burning, acid reflux, taste in the mouth, vomiting, thirst, hunger, and food preferences. Additional questions evaluate cough and other symptoms related to the lungs and large intestine.

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    This document contains a diagnosis form for natural health that collects personal information such as name, address, email, phone number, occupation, sex, marital status, age, height and weight. It then asks questions to assess symptoms related to the spleen and stomach, such as appetite, stomach pain, bloating, burning, acid reflux, taste in the mouth, vomiting, thirst, hunger, and food preferences. Additional questions evaluate cough and other symptoms related to the lungs and large intestine.

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    © All Rights Reserved
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    15 views1 page

    Heshoutang Diagnosis Form of Natural Health: Personal Information

    Uploaded by

    Rost Yomboun
    This document contains a diagnosis form for natural health that collects personal information such as name, address, email, phone number, occupation, sex, marital status, age, height and weight. It then asks questions to assess symptoms related to the spleen and stomach, such as appetite, stomach pain, bloating, burning, acid reflux, taste in the mouth, vomiting, thirst, hunger, and food preferences. Additional questions evaluate cough and other symptoms related to the lungs and large intestine.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    HESHOUTANG DIAGNOSIS FORM OF NATURAL HEALTH

    Personal Information
    Name: Address:
    Email: Phone: Occupation: Referred by
    Sex: M F Marriage: Y N Age: Children: Ht/Wt:
    Main Problem: How Long:
    Spleen & Stomach(SS)
    Appetite
    Normal Strong Low No Appetite
    Stomach Pain
    No Dull Pain Sharp Pain Movable Pain
    Around Belly Button
    No Dull Pain Sharp Pain Movable Pain
    Stomach Bloating .
    Na Slight Serious
    Burning Stomach
    No Slight Serious
    Acid RefluX•
    No Slight Serious
    Taste in Your Mouth
    Normal Sweet Acidic Odor Bitter Bad Breath No Taste
    Vomiting
    No Retching With Undigested Foods
    With Thin Mucus & Phlegm
    Often Thirsty
    Normal Slight Much
    Easily Hungry
    Normal Slight Much
    Prefer Foods
    Normal Cold Hot Spicy
    Alcohol & Wine
    Lungs & Large Intestine(LL)
    Cough

    18

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