Kampo Health Questionnaire

New Patient Form
Fill out and submit the form online via secure internet connection.

Note: It is important that you list your email address accurately and state reachable phone numbers so that we can contact you promptly.

If you are not patient of The Pacific Wellness Institute or you are not active patient (last visit more than a year ago), please submit both General and Kampo forms.

General Health Questionnaire -> Online SSL Form

Kampo Constitutional Evaluation Form -> Online SSL Form