Please obtain the Patient Identifier number from us before applying. For privacy and security reason, do not fill in your name, email address and phone number here. Instead, only use your patient number in this form and other forms as well. This number is the identifier for each individual patient and the link for all Responses to Questions here to the same person. Therefore, do not use other people's number.
Enter your Patient Identifier Number (PIN) only. Do not use other people's PIN.
Height in inches
Enter total inches of your height, eg. 5' = 60", 6' = 72", etc.
Weight in Pound
Enter numbers only
Systolic Blood Pressure (mmHg)
The higher number appearing on reading. Enter number only.
Diastolic Blood Pressure (mmHg)
The lower one appearing on reading . Enter number only.
Fasting Blood Sugar (mg/dL)
Enter number only.
Normal heart beats/min
This is the one when you are not sick. Enter number only.
No smoking at all
No drinking at all
Drug addiction or Intoxication if any including marijuana
List all allergen sources, including but not limited to food, drug, supplements, pollen, etc.
List any or all prior medical conditions:
List any medication/purpose
List any dietary supplement or essential oil/purpose
Family medical history:
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