Online Kampo Medicine Questionnaire

Thank you for your interest in Kampo medicine and acupuncture treatment at Kakikofu.

To purchase Kampo herbal medicine or receive acupuncture treatment, please make an appointment in advance. We may not be able to accommodate walk-in visits without a reservation.

👉 Click here to book your appointment
https://kakikofu.com/en/en-contact/

If you are requesting acupuncture treatment only:

Simply book your preferred date and time. Please arrive at the clinic at the scheduled appointment time.

If you are requesting Kampo herbal medicine:

Before your appointment, please complete and submit the questionnaire below.
Kaori, our Kampo specialist, will review your responses and prepare your personalized herbal formula in advance.

Items marked with an * (asterisk) are required.

Personal Information

※Full Name

※Email

※Email (Confirmation)

※Country / Prefecture

※Age

※Gender
FemaleMale

Main Health Concern

※What is the main symptom or issue you would like to improve with Kampo medicine?

How long have you had this symptom?

Are you currently undergoing any treatments or taking any medications? If so, please provide details.

Do you have any allergies? Please specify the type.

Do you experience constipation or diarrhea?

How is your digestive condition? (e.g., weak stomach, nausea, bloating)

Do you have mental or emotional stress or mood-related symptoms?

Do you have any sleep-related issues?

Medical History

Please list any past illnesses, injuries, or medical conditions you have had.

Constitution & Body Type

Do you feel cold easily? Which parts of your body get cold?

Do you experience a sensation of heat or hot flashes? Where?

Do you sweat easily? If so, where on your body do you sweat the most?

How are your bowel movements? (e.g., soft stool, constipation, frequency)

How is your urination? (e.g., color, smell, frequency, nighttime urination)

How is your sleep? (e.g., shallow sleep, dreams, frequent waking)

Do you experience swelling? Where and at what time of day?

Do you feel emotional or psychological stress? Can you identify the cause?

Do you feel physical fatigue?

Questions for Women

Is your menstrual cycle regular? If not, please describe.

How many days does your period usually last?

Do you experience any symptoms associated with your menstrual cycle? If so, what kind and when?

Do you have menstrual pain?

Do you experience vaginal discharge?

Others

Please let us know if you experience any of the following:
Headaches, dizziness, lower back pain, stiff shoulders, nasal congestion, tinnitus, indigestion, joint pain, itchy skin, or any other concerns.

Also include any issues aside from your main complaint.

Tongue Photo Upload

In Kampo medicine, the tongue reflects the condition of the internal organs.
To better understand your overall health, please take a clear photo of your tongue and upload it with this form.

Here is a sample photo of the tongue. Click to enlarge.

Surface of tongue：

Underside of tongue：

Other Information

Your Request
I would like to purchase Kampo herbal medicine onlyI would like to receive both Kampo herbal medicine and acupuncture treatment

Pricing Information

How many days of Kampo herbal medicine would you like?
The cost of Kampo medicine is approximately 700 yen per day.
(Please note: The exact price may vary depending on the prescription.)
15 days30 daysMore than 30 days

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Please review the information and check the box once you confirm it.
I have reviewed the information. I will proceed with sending it as stated above.

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