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Detect a Cancer in the Early Stage Questionnaire
First Name: * E-Mail: *
Last Name: * Birth Date: *
Address:  Home Phone:
City, State, Zip: Alternate Phone:

Please read every item carefully and put a check mark in the box next to each item that applies to you.

Let us know about your main health complaints and any items you do not understand below:  If you need any help, please call (817) 469-8823.

 1 I have breast implant
 2 I have tubal ligation
 3 The color of urine is amber (dark yellow)
 4 My urine has many bubbles.
 5 My urine has sign of the blood.
 6 Nasal bleeding myo bleeding (skin purpura) with fever, anemia
 7 Whites (leukorrhea) coupled with blood or bleeding after sex or vagina bleeding
 8 All of sudden, stool becomes very thin; and the blood is seen in the stool
 9 Black stool or black blood in the stool
10 Hemoptysis (spitting blood from the lungs or bronchial tubes)
11 Sputum / phlegm contains the blood
12 Blood in the semen
13 Blood in the urine; yet no pain
14 Always feel hot (low grade fever) or sensitive to heat and like cold weather
15 Has kidney function (immunity) or spleen (pancreas) and /or liver function problem
16 Feel sad, anxiety, frustration, anger, depression or other emotional stress

List the vitamins, minerals, and other food supplements taken

18 Has not taken any vitamins and minerals
19 Female hormone such as estrogen, progesterone is high
20 Male hormone is high
21 Cortisol is high
22 Excessive sex desire (kidney and liver fire) 
Cushing syndromes (adrenal cortical physical)           
23 Prostate cancer
24 Ovary cancer
25 Breast cancer
26 Thyroid cancer
27 Immune deficiency by birth
28 Breast over development for a male (excessive female hormone)                                              ?????
29 Blood stasis minifested on the neck, clarvicle, inguinal, along the spine
30 Persistent hiccough (related to emotion)
31 Amalgam in the tooth root canal history
  32 Has Eb toxin-lymphatic tumor, EBV for NasoPharnygeal,
C type RNA for leukemia
33 Incline to eat high protein, spicy, greasy (fried chicken, french fries) food
34 Eat or drink the vegetables, water, fruit, or peanut, corn polluted by pestcide, herbcide
35 Love to eat peanut, corn (contain aflatoxin)
36 I smoke.
37 Consume alcohol
38 Exposed to radiation such as ultraviolet radiation, Gama, X ray, ionizing radiation
39 Has chronic ulcer, infection, scalding, or scar tissues (related to epidermal EGF)
40 Take chloromycetin or phenylbutazone
41 Expose to waster gas (amonia), chemical liquid, polluted air, chemical fertizer
42 Expose to asbestos, coal tar, coal smoke, mustard gas, asphalt, formaldehyde (lung/Leukemia)     
43 Feel tumor in cervical lymph node (coming from clarvicle)
44 Feel tumor in auxillary lymph node
45 Feel tumor in submandibulla, inguinal lymph node
46 Persistent itching all over the body or nasal itching
47 I have Herpes
48 I have high tolerance of pain
49 I have marginal nevus (junctional nevus) or hemorrhoids
50 Poor appetite, feel bloated, nausea ( Pancreas, liver, stomach, colon cancer)
51 I have dysendocrinism, metabolic disorder, rheumatoid arthritis
52 Neurotrophic disorder (edema, nerve ending infection, limb numbness, myoasthenia)
53 Rapid growth of lanugo hair (fine, soft lightly pigmented fetal hair)
54 Fungus appeared on the skin
55 Leukoderm (white spots ) or black spots on the skin

For over 4,000 years, the Chinese have traditionally used herbal formulas to aid in recovery from various diseases and to promote abundant health.  These suggestions are for your education only.  Any suggestions we may make to assist your recovery are based on the information you provided.  They are not intended to diagnose, treat, cure or prevent any disease.  The decision to take any Chinese herbal formulas is up to you.  The Federal Drug Administration has not evaluated these formulas.  Please provide feedback two weeks after taking the formulas.

Please put your initial to indicate your request for review of your medical information.

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May you be blessed with abundant health

Alternative Medicine Inc.
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