Date of Birth: / Month:
County / City:
Province / State:
Closest friends, phone:
How do you know us:
Health assessment in recent years? Please check any problem areas:
Autonomic nervous system
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?：
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)
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.
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)