To: postmaster@herbalpalace.com
From: [required-eaddress]
Subject: QUESTIONNAIRE COMPLETED

The following information was submitted through the diagnostic questionnaire:

PERSONAL INFORMATION:
Name = [required-name]
email = [required-eaddress]
Address = [required-address]
Phone = [required-phone]
Age = [required-age]
Sex = [sex]
Occupation = [occupation]

PROBLEM INFORMATION:
Problem = [problem]
Severity = [severity]
Duration = [duration]
Problem Comment = [problemcom]

BODY TYPE AND ENERGY LEVELS:
Body Type = [bodytype]
Energy = [energy]
Body Type  Comment = [bodytypecom]

BLOOD PRESSURE INFORMATION:
Blood Pressure = [bp]
Value = [bpvalue]

PAIN INFORMATION:
Pain Type = [paintype]
Pain Location = [painloc]
Pain Comment = [paincom]

THIRST:
Thirst = [thirst]
Thirst Comment = [thirstcom]

FEVER-COLD-CHILLS
Fever/Cold/Chills = [fsc]
Comment = [fevercom]

EMOTIONAL:
Emotions = [emotion]
Comment = [emocom]

COMPLEXION-SWELLING-SKIN
Complexion = [complexion]
Edema = [edema]
Comment = [swellcom]
Skin = [skin]

EYES-EARS-NOSE-THROAT:
Eyes = [eyes]
Eye Comment = [eyescom]
Ears = [ears]
Ears Comment = [earscom]
Nose = [nose]
Nose Comment = [nosecom]
Throat[throat]
Throat Comment = [throatcom]

MOUTH-LIPS-TEETH:
Mouth/Lips/Teeth = [mlt]
Comment = [mouthcom]

HEAD-NECK-CHEST:
Head & Neck = [headneck]
Comment = [headcom]
Chest = [chest]
Comment = [chestcom]

STOMACH-DIGESTION:
Stomach = [stomach]
Comment = [stomachcom]
Stools = [stools]
Comment = [stoolscom]

URINATION:
Urination = [urine]
Comment = [urinecom]

FEMALE-MALE RELATED PROBLEMS:
Gynocological Problems = [gyno]
Comment = [gynocom]
Male Problems = [man]
Comment = [mancom]

TCM PULSE-TONGUE
Tongue = [tongue]
Comment =[tonguecom]
Pulse =[pulse]
Comment = [pulsecom]