To order Custom Herb Formulas, prepared and mailed directly to you please fill out the form below:

ORDER OR INQUIRE ABOUT HERB FORMULAS.

CONTACT INFORMATION	FIRST NAME: LAST NAME: ADDRESS: CITY: STATE: Zip: E-mail Address:
CHIEF COMPLAINT
BRIEF HISTORY
AGE
HAVE YOU BEEN TAKING MEDICATION? PLEASE INDICATE WHAT TYPE AND FOR HOW LONG.
ARE YOU EXPERIENCING FEVER, NIGHT SWEATS OR ARE YOU HOT OR COLD?
DESCRIBE URINARY FREQUENCY OR URGENCY
PLEASE INDICATE IF YOU HAVE CONSTIPATION, DIARRHEA OR NORMAL STOOLS
DO YOU HAVE ANY OTHER BODY PAIN, PLEASE BE SPECIFIC
ALLERGIES
ARE YOU PREGNANT
DO YOU HAVE ANY MENSTRUAL IRREGULARITIES?
WHAT IS YOUR WEEKLY ALCOHOL INTAKE
PLEASE RATE YOUR STRESS LEVEL ON A SCALE OF 1-10 (1=CALM AND 10=VERY STRESSED)
WHAT EMOTIONS HAVE YOU BEEN EXPERIENCING EXCESSIVELY, I.E., ANGER, WORRY, ANXIETY, ETC.
APPETITE	HUNGRY NO DESIRE TO EAT THIRSTY
FLUID INTAKE PER DAY
SLEEP	GOOD INTERRUPTED INSOMNIA
MEALS TAKEN DURING A TYPICAL WEEK	BREAKFAST LUNCH DINNER