Save and Continue Later Send Client Intake Form - Cold and Flu Surname Given Name * Date of Birth * Gender * Male Female Others Phone Number * Email Address * Confirm Email * Address Main Complaints Energy level (out of 10, 10 is highest energy) Are you prone constipation or prone diarrhea Do you feel aversion to wind or cold? Do you sweat easily? Any night sweat? Any chill like body aching sensation? How often you have headache or migraine? How often you urinate, any night urination? List of Medication intake Do you have any allergy? Any special diet restriction, eg. Vegetarian , paleo or keto? How would you like us to support you?