Name Street Address Address (cont.) City State/Province Zip/Postal Code Country Phone FAX E-mail
How would you rate your overall health?
Good O.K. Poor
Do you sense a general, steady decline in your ability to live a healthy, energetic, and vibrant life?
Yes No
Are you putting on weight you can't seem to get off?
Is your thinking confused of "fuzzy"?
How would you rate your skin?
Beautiful So-so Damaged/Aged
How are your teeth?
Good Periodontal Disease Losing them
Have you a sex life?
Satisfactory Fading You're got to be kidding
Have you been diagnosed with Diabetes II?
Do you think your immune system has been compromised?
Were you aware that your internal organs shrink as you age?
Do you have insomnia?
Are your joints functioning smoothly?
Do you have gout or a tendency to gout?
Do you have digestive problems?
Are you constipated?
How is your eyesight?
Fine Fading Serious problems
Are you under a great deal of stress?
Do you have heart or circulatory problems?
Acupuncture Medical Clinic
Find Quality Herbal Remedies on the Internet in an Organized and Structured Online Catalog