Online Diagnostic Questionnaire for Kampo medicine

Personal Information

Main Concern

Medical History

Regarding feces and stool

■Bowel Movement Frequency：Every dayOnce every 1-2 daysOnce every 3-4 daysNo bowel movement for 5 or more days

■Condition of Stool：Pellet-like stoolHard stoolSoft stool/diarrhea proneStarts hard, then becomes soft stoolAlternates between constipation and diarrhea

■Constipation：ConstipatedBloated abdomenDifficult to have a bowel movement when people are aroundEasier to have a bowel movement on holidays

■Other Stool Conditions：Excessive gasHemorrhoids presentHistory of hemorrhoids

■Daytime Urination Frequency：1-3 times4-6 times7-10 times

■Nocturnal Urination：1-2 times3 or more timesOnly in winter

■Other Urinary Conditions：Feeling of incomplete emptyingPain during urinationUrinary leakage

About the body in general

■Constitution：Sensitive to coldSensitive to heatProne to chilblainsProne to feeling flushedSweats very littleTires easily, fatigue doesn't go awayProne to catching colds

■Sweating：Heavy sweating 　●Areas prone to heavy sweating： 　Face/headUnderarmsPalms/solesGroin

■Cold Sensitivity：Prone to feeling cold 　●Areas prone to feeling cold： 　Hands/feetLower bodyWhole bodyAbdomen

■Flushing：Prone to swelling 　●Characteristics of swelling： 　Swells in hands/feetSwells in lower bodySwells in faceSwells in the eveningSwells from the morning

■Swelling：Prone to swelling 　●Characteristics of swelling： 　Swells in hands/feetSwells in lower bodySwells in faceSwells in the eveningSwells from the morning

Mental State and Sleep

Feel stressedEasily tenseEasily irritated or prone to outburstsProne to feeling depressedAnxious or worriedFrequently forgetfulFall asleep easilyHave trouble falling asleepWake up in the middle of the nightOften have unpleasant dreams

For Women: About Menstruation

■Menstrual Cycle：Regular (25-35 day cycle)Tends to be early (24 days or less)Tends to be late (36 days or more)IrregularAlready in menopause

■Menstrual Period Duration：Within 3 days4-7 days8 days or more

■Premenstrual Symptoms：Have premenstrual symptoms

■Menstrual Pain：Have premenstrual symptoms 　●Characteristics of menstrual pain： 　Pain starts before the periodPainful on the 1st-2nd dayPainful from the 3rd-4th day onwards

■Vaginal Discharge：Concerned about vaginal discharge 　●Characteristics of vaginal discharge： 　Occurs mainly during ovulationWatery dischargeYellowish and has an odorAccompanied by itching

About Different Parts of the Body

■ Headache：Pain in the templesPain in the back of the headPain in the foreheadTightening painThrobbing painHeavy-headedness

■ Dizziness：LightheadednessSpinning sensationFeeling faint when standing up

■ Eye Problems：Easily tired eyesDry eyesBlurry visionDecreased visionBloodshot eyesItchy eyesPresbyopia (age-related farsightedness)

■ Ear Problems：High-pitched tinnitusLow-pitched tinnitusHearing lossEar fullness

■ Nose Problems：Nasal congestionRunny noseSneezingNosebleeds

■ Throat Problems：Feeling of something stuck in the throatSore throatEasily dry throatThick phlegmWatery phlegm

■ Stomach and Intestinal Problems：IndigestionHeartburnAcid refluxLack of appetiteStomach pain when hungryStomach pain after eatingStomach pain due to nervousness

■ Pain：Lower back painJoint painNumbness in hands or feetPain due to injury

■ Skin Problems：ItchingRednessPus formationPainBlistersAge spotsDull skinSagging skinNasolabial foldsWrinklesDry skin

■ Other Problems：Stiff shouldersStiff neckStiff backPalpitationsHigh blood pressureLow blood pressure

Tongue Photos(Required)

Purchase Preferences(Required)

Plan to visit KakikofuPurchase request from outside Japan
Please understand that if you live overseas, there may be limitations on shipping from our store. Therefore, please verify if Chinese herbal medicine is available for purchase in your area. If you are in the United States or Poland, we can introduce you to clinics affiliated with our store where you can make purchases.

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