Arcadia Holistic Health Care Medical Center

9819 Las Tunas Dr. Temple City, California 91780

Tel: (626) 292-7755 Fax: (626) 285-8566

Medical Service Form Ref.. No.

The fields in green color are required to be filled out by patients.
Patients. Name: Pat.’ S.S.N.:
D.O.B.: M/ D/ Y/ Drive #:
Sex: M F Address:
City: State:&Zip:
Phone No.: Email:
Occupation: Marital: S M D W
Work. No:/Fax No.: Chief Complaint,

Ht.: Wt.: Temp.:
Referred By: Radio TV News Other
Tongue color: Tongue Coating: pulse left: pulse right: constrictedbeats/min: , female, date of last period: mth. day yr. # of children? Please circle your symptoms below and rate the severity from 1-9. If a symptom is not listed, please write it in and rate it.
1.Frequent colds? YES NO;  # of times/ yr. 2.Stuffy nose? YES NO;  AM PM all the time
3.Sneezing? YES NO; Times/ day? 4.Thin or thick discharge? YES NO; # of tissues/day
5.Post nasal drip/ phlegm? AM PM all the time 6.Head septum throat;  pain dizzy; how often?
7. Bad breath cold sores dry mouth;   how often? 8.Stomach chest pain nausea acid reflux
9.Neck shoulder back pain? How long? 10.Hearing sense bad? Smell sense bad? How long?
11.Itchy nose ear eye throat skin  itchy? 12. Coughing asthma AM PM # of times?
13. cold sleepy stressed  fatigued? How long? 14. Restless sleep no sleep? How often?
15. Dizziness Rapid heartbeat 16. Snoring ringing pressure in ears voice lost how often?
17. Excess weight loss 18. Yellow urine diarrhea constipation?
19. Stress?  How often? 20.Smelly nose? YES NO; Much nasal waste? YES NO; How long?
21. Nose bleed hemorrhoids blood in feces?  How long? 22.Have you had nasal surgery? YES NO;  # of times?
23.Smoke drink;  how long? 24.Allergy? YES NO; To what?
25. Feminine discharge excessive menstruation menstrual pain? 26. Thirsty cravings much urine;  AM PM all the time;   how often?
27. Limbs joints ache or pain. 28. Heaviness loss of appetite bloating?
29.Blood pressure high? YES NO;   cholesterol high? YES NO 30.Other
Other Complaint: fever, snoring, chest congestion, no voice, nose bleeds, nasal septum pain, tiredness, smelling deteration, hearing deteration, ear ringing, pressure in ear, swollen lymphoid glands, excessive weight loss, earache, dizziness, sensitivity to light, bland taste buds, acid reflux, hermeroids, blood in feces, insomnia, restless sleep, itchy/painful skin,. Frequent colds? Do you frequently eat cold foods, spicy foods? Smoke? Have you had children? Menstrual cramps? If there are other problems please write it in the space provided?
**Due to the time difference between many other states and California, if you are seriously interested in developing a healthy future, please fill out the information above and fax it back to my office at: 626-285-8566 as soon as possible. In addition to faxing the information back, please leave your number so I may call you back and analyze your disorder with you: City area code and phone number: Ext. In addition, by first telling me exactly when, you will contact me: Month? Day? Mon~Sat? Time in Pacific Time Zone.

NOTE: I certify that the information that I have provided above is true. I have been told and understand the benefits of the treatment and am aware of the tiny risk involved. I give my consent for treatment, and take full responsibility of this treatment. Those diagnosed with cancer or are using special treatments need to acknowledge that this is not an alternative treatment.

FEE: Economic Method $200.00/cycle. Express Method $300.00/cycle. In addition to $10.00 for shipping and handling charges. Method of Payment: Money order or Check Visa Master card,
Card No. / / /(xxxx) Exp.: Mon/ Day/ Year
Card holder Name: