Patient Name: Time:

Date of Birth: / Month: Date: Year: Gender: Age: Marital status: Single Married Divorced Others:

Address: County / City: Province / State: Zip:

Mobile: Home: Work: Other:

Occupation: E-mail:

Height: Weight: Fat Thin Tall Short

Closest friends, phone: How do you know us:

Health assessment in recent years? Please check any problem areas: Liver Heart Spleen Lung Left Kidney Right Kidney Small Intestine Colon Pancreas Bone Marrow Cervical Left Sinus Right sinus Autonomic nervous system
Left ovary Right ovary Uterus. Last menstrual period:

You often do you catch cold? frequency per year? Times. What are your physical symptoms? How long do they last? Have you used Western medial doctors? How long has it been since your last checkup What were the results: History of surgery? What type of surgery?

high blood pressure?: low normal high Family: Blood Type Sleep: Good/ Poor / Other

If you have the following symptoms, please fill in circle and mark how long? Such as months, years, and the degree of disease, such as: 1 to 3 indicated mild, moderate 4 to 6, severe 7 to 9 to indicate severity (Normally, morning = am getting up two hours, the night = night or in the middle of the night)

Symptoms And History

Series of symptoms of nose

Series of symptoms such as sinusitis

Series of allergy or virus symptoms of the body




Dripping Nose

Pain in bridge of the 1) nose
2) sore throat
3) front of head

Dry nose membrane with foul smell

1) neck and shoulder pain
2) back of head

1) Stomach 2) burning pain
3) nausea


Cough and asthma

Chills part: sleepiness fatigued

Emotional stress insomnia frequent dreams

How long?
Level (0-9)

Symptoms and History

Auto immune symptoms Series

Other important issues

Has the following allergies:

2)Hearing loss

1)Foul nose smell
2)Numerous bogger

2) blood in the stool
3) constipation

Nosebleed part:

1)Heavy snoring
2)ear tinnitus

How long?
Level (0-9)

If the symptoms are the following special, please select circle, and a brief description of:frequent fever facial nerve hands and feet numbness chest tightness ear ache giddy hoarseness sensitive to light lymphadenopathy drastic reduction of body weight food tasteless acid reflux skin hives skin pain peeling hair loss frequent urination at night menstrual pain vaginal discharge palpitations fulstered pressured anxiety troubled trouble memory inability to concentrate amnesia eat cold and cool atsumi

I have carefully read and truthfully answered the above problems to best of my ability, I also understand as with all medical treatment there is no guarantee of 100% recovery. In addition, sufferers of pre-diagnosed chronic ailments who are currently under medical treatment are discouraged from using this treatment as their sole existing treatment. I, the patient, am responsible for fully cooperating with the doctor's medical advice to ensure maximal efficacy of treatment. If there are any questions please call 626-292-7755 or fax 626-285-8566 if outside the United States need to add the country code, such as the United States from Taiwan when allocated :00-2-1-626-292-7755.

Basic course treatment cost is $120 + $10.00 shipment fee (one day cure 1) may use 12 days.

Advanced course treatment cost is $ 199.00 + $ 10.00 Shipment fee (one day treat 2. The nose 1 anus 1) were available for 12 days

Treatment course lasts 6 days with 1 day of rest. I am willing to pay using the following method: Money order. Visa card, Master card,
The Card No. / / /(xxxx) Exp.: Month/ Day/ Year
Card holder Name:

The undersigned patient acknowledges that the doctor has already provided a detailed explanation regarding the above listed nasal ailments' pathology and mechanism aspects of treatment.  The undersigned patient furthermore agrees to fully cooperate with the doctor in order to achieve the greatest treatment results.  The patient also affirms his or her knowledge of US treatment law.  The patient cannot request the doctor to guarantee a 100% cure. If necessary I also consent to acupuncture, herb, treatment care. The patient also gladly accepts responsibility to pay all necessary treatment costs. 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 risk involved.  I give my consent for Money order. 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

Please fill out the above form first, please be as clear as possible as it will aid in your diagnosis. If this is a repeat treatment, please put a number corresponding to your treatment number after your name on the form. Payment must be paid with either Visa, Master Card, or Paypal prior usage of site. You will receive a pin number that will allow you access to the checkup process.

1. Please place 3 Q-tips in your mouth and click play begin listening to the illumination music (3 minutes long). After 1 minute remove one of the q-tips and mark the q-tip as #1 and move your tongue up. After the 2nd minute remove another q-tip and mark it as #2 and then close your eyes. At the end of the music, remove the last q-tip and mark it as #3.

2. Wrap the used q-tips in plastic wrap, or place in a small zip loc baggie. Click the “allow” button to access the recording function on your computer. Then hold the wrapped tips in your hand and click the record button. While holding the wrapped tips in your hand, SLOWLY count to 30. After counting to 30, click the stop button. Then play back to verify that the recording was successful. If not, please go though the removing process again. If you are satisfied with the recording please hit the submit button to send the recording to us. If you have any questions you may contact us at 626-292-7755 for assistance.

3. Once we have received your recording, we will be able to determine the internal or external cause of your ailment. We will also suggest proper treatment using our unique DNA biofeedback customized to your ailment.

Listen to this first: Then record your DNA:

Listen to this first: (請先以信用卡付款再聽放大音樂)

Then record your DNA: *you must press ALLOW to record