Online Diagnostic Questionnaire for Kampo medicine

At Kakikofu, we offer online Kampo consultations. If you can visit our store in Tokyo, please send this diagnostic questionnaire first. It will be used as a reference during your consultation on the day.

For those inquiring from overseas:

Many countries make it difficult to ship Kampo medicines from Japan. Customs often stop and dispose of them or return them to Japan. Therefore, we generally do not ship Kampo medicines overseas. Exceptions may be made for countries where shipping is possible or for supplements. In such cases, we use EMS for shipping.

Please consult with us for details.

Kampo consultations cost 5,000 yen.

(If you purchase Kampo medicines from our store, the counseling fee will be waived.)

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If you have not received a reply from Kakikofu within three days, please contact us by email.

印のある項目は必須入力項目です。

    Personal Information

    Full Name


    Email


    Email (Confirmation)


    Country / Prefecture


    Age


    Gender
    FemaleMale

    Main Concern

    What is your main symptom?


    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?

    Medical History

    Any previous illnesses or injuries?
    In traditional Kampo medicine , emphasis is placed on individual constitution and physical condition rather than the specific disease name. Please review the following checklist and check any items that apply to you. These are crucial factors when determining Kampo medicine.
    Please check the items that apply to you:(Check applicable)

    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:[checkbox checkbox-02 "Pellet-like stool" "Hard stool" "Soft stool/diarrhea prone" "Starts hard, then becomes soft stool" "Alternates between constipation and diarrhea" ■Constipation:[checkbox checkbox-03 "Constipated" "Bloated abdomen" "Difficult to have a bowel movement when people are around" "Easier 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 ●むくみの特徴:Swells in hands/feetSwells in lower bodySwells in faceSwells in the eveningSwells from the morning

    Mental State and Sleep

    (Please check the items that apply to you)
    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

    (Please check the items that apply to you)
    ■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 ● Types of symptoms:SwellingIrritabilityBreast tendernessTendency to overeatNight sweatsFlushingConstipation ■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

    (Please check the items that apply to you)
    ■ 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)

    Here is a sample photo of the tongue. Click to enlarge.
    Upload photos of the front and back of the tongue for accurate diagnosis.
    Surface of tongue:
    Underside of tongue:

    Purchase Preferences(Required)

    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.

    Other questions or requests

    (If you wish to receive acupuncture treatment at our clinic, please indicate so here.)

    No confirmation screen will be displayed. Please review the information and check the box once you confirm it.