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Personal Information

To our Valued Clients:

Kindly fill out the Personal Information below.  After you have successfully completed this part,  you will be taken to the next pages which will contain some questions pertaining to your health (current and past). 

Choose the symptoms and relative severity you may have. Please DO NOT CHECK THE SYMPTOMS YOU DON'T HAVE.

The survey may take about 10-15 minutes to complete.  It contains several aspects of health – and this is important for our Practitioners so that they have a better understanding of your situation and come up with the appropriate plan for you.

Let’s start!

First Name

Middle Name

Family Name

Cell Phone

WeChat Code

Email Address

Address (Apartment/Unit#, Street, City, Postcode.)

City

Province

Country

Post Code

Gender

Date of Birth

Temperature(Ear ℃)：

Weight (kg):

Height (cm):

Blood Pressure: (eg:120/80 mm Hg)

Heart Rate (How many beats per minute? eg:75 beats per minute):

Language: