Self Assessment Health Questionnaire-Required

This assessment profile can be used as an educational device as well as a diagnostic tool to aid you in becoming acquainted with the categories of Chinese medicine. When filling out the form, you might notice the same or similar questions repeated in different sections. It is important to answer these questions, if applicable, for each instance they occur. This provides insight into possible patterns for a more complete picture.

If making an appointment for a distance healing/instruction session, note a 48 hr. cancellation notice is required to avoid full session fee.

Please follow the directions below to fill out and return the Questionnaire.

  • Right-click  (or Ctrl-Click on a Mac) on the link below.
  • Choose the Save Link as… option from the drop down menu.
  • Save the document to your local hard drive.
  • Open the document once it is saved and fill it out.
  • When you are finished, be sure to save the document again and then email it to info@longevity-center.com at least two days prior to your appointment.

» Self Assessment Health QuestionnairePDF (65 Kb)

Please note:

The Self Assessment Health Questionnaire is provided for informational purposes only. This information is not intended to substitute professional medical advice or service. You should not use this information to diagnose or treat a health problem without consulting with a qualified healthcare provider. The Longevity Center will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom.