Kampo Initial Intake — Four Examinations (Shi Zhen)

Kampo Initial Intake Form

Please complete this form after booking your appointment.
Fill in what you can — the more you share, the deeper the diagnosis we can provide.

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We will be in touch within 2 business days.

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All fields are optional — please fill in what you can. Press "Submit" when done.
01Basic InformationBasic Info
02Reason for VisitChief Complaint
03Current ConditionCurrent Condition
04Constitution AssessmentShi Zhen

Check all that apply (multiple OK). The more items checked, the stronger that tendency is likely to be.

Qi Deficiency (気虚)0

Low energy type

Qi Stagnation (気滞)0

Qi flow stagnation type

Blood Deficiency (血虚)0

Blood insufficiency type

Blood Stasis (瘀血)0

Poor blood circulation type

Yin Deficiency (陰虚)0

Fluid deficiency / heat accumulation type

Phlegm-Damp (痰湿)0

Fluid metabolism stagnation type

Yang Deficiency (陽虚)0

Warming function deficiency type

Excess Heat (実熱)0

Excess heat type

05Photos & VideosPhoto / Video

The following photos and videos help improve diagnostic accuracy. Please send them via LINE or email after submitting this form.

  • Photo of the tongue (mouth open, natural light)
  • Photo of the eyes (showing whites / surface of eyeball)
  • Affected area (skin, ears, etc.)
  • Video of gait / movement (if lameness or wobbling present)
  • Blood test or other lab results from your primary vet (if available)
06Questions & NotesOther

We will be in touch within 2 business days of receiving your form.