1. Fill out the form as best you can. If you don’t know the answer, say you don’t know or N/A. Allow yourself 20-30 minutes to complete the form.

2. Submit the form by pressing the Submit button at the bottom of the page and Alina will review and evaluate your information free of charge.

3. Based on her evaluation, Alina will prescribe a Personalized Formula for your specific condition or ailment.

4. Within 48 hours you will receive an email with a link to purchase your Personalized Formula for a standard rate of $35 dollars, which includes shipping.

5. Submit your billing and shipping information.

6. You will receive an email with a tracking number.

7. Your Personalized Formula will arrive within 3-7 days from the shipping date.

Online Herbal Formula Consultation

At Alina Sepeda Herbal Medicine, we believe in the power of Chinese herbs so much that we do online herbal consultations for free. This could cost you up to $150 to see a licensed herbalist in your community. But here, you can get a formula prescribed to you specifically for your condition from a licensed acupuncturist and herbalist for free. And you never have to leave your home.

1. Your Name

2. Your Email

3. Gender

4. Age

5. Occupation

6. Weight

7. Height

8. Marital Status

9. Number of children and Ages

10. Hobbies

11. How did you hear about us?

12. What is your chief concern?

13. When did it start?

14. What makes it better?

15. What makes it worse?

16. Have you received a diagnosis from a doctor regarding this concern and if so what
was the diagnosis?

17. Do you take anything for it and if so what?

18. Does it make it better?

19. Have you seen any other practitioners about this concern and if so what kind of
practitioner?

20. What were their recommendations?

21. Do you have any lab/physical exam results about this concern and if so what were the values/results?

22. Any secondary concerns?

23. Please list any other medical diagnoses you have received from other healthcare practitioners.

24. Please list all medications, remedies, and supplements you currently take.

25. Please list all allergies to medications, food, etc.

26. Please list past serious illness, injuries, and operations with dates.

27. On a scale of 1-10, what is your energy usually, with 1 being extremely sluggish and 10 being full of energy?

28. Do you ever feel your heart beating in your chest?

29. Does your body and/or head ever feel heavy?

30. Do you feel like you have foggy thinking, especially in the morning?

31. Do you have ringing in your ears?

32. If so, is it high-pitched or low pitched?

33. Do you experience dizziness?

34. Do you get hungry for 3 meals a day?

35. Are you a vegetarian?

36. Do you drink coffee?

37. How many cups per day?

38. Do you drink alcohol?

39. How many drinks per week?

40. Do you smoke?

41. How many cigarettes per day?

42. What is a typical breakfast for you?

43. What is a typical lunch for you?

44. What is a typical dinner for you?

45. Do you have gas and/or bloating?

46. Do you burp excessively?

47. How many bowel movements per day do you have?

48. Do you skip days?

49. What is the consistency generally?

50. Is there mucus in your stool?

51. Is there blood in your stool?

52. How many times a day do you urinate?

53. What is the color usually?

54. Do you have one or more of the following symptoms?
 Burning Pain Difficulty Dripping N/A

55. Do you urinate during the night?

56. How many times?

57. Do you sweat easily?

58. Do you have night sweats?

59. Do you wake up damp or soaked?

60. Do you find you are often thirsty?

61. What temperature of liquid do you prefer?

62. Do you get more thirsty in the afternoon/evening/nighttime?

63. Do you have a dry mouth?

64. Do you have a bitter taste in your mouth?

65. Do you tend to be more on the cold side or the warm side?

66. Do you regularly have cold/hot hands and feet or just one of those?
 Cold Hands Hot hands Cold feet Hot feet N/A

67. Do you have trouble sleeping?

68. Trouble falling asleep?

69. Trouble staying asleep?

70. Vivid dreams to the point of disturbing your sleep?

71. Do you wake up at a certain time every night and if so what time?

72. How many times per week do you exercise?

73. What kind of exercise?

74. In general, what is your emotional state?

75. When things go wrong, what emotion do you tend towards?

76. On a scale of 1-10 with 1 being mild stress and 10 being unbearable stress, how stressful is your job?

Questions #77 - #95 Are For Females Respondents Only. Male Respondents Please Skip to #96

77. Do you menstruate?

78. How long is your cycle?

79. Is it regular?

80. How long is your bleed?

81. What color is the blood in the beginning of your period?

82. What color is the blood in the middle of your period?

83. What color is the blood at the end of your period?

84. Do you bleed a small/moderate/large amount?

85. Do you have clots and if so are they larger or smaller than a dime?

86. Do you experience PMS symptoms and if so, what are they?
 N/A No symptoms Breast tenderness Cramps Irritability Sadness Bloating Nausea

87. Do you get cramps during your period?

88. Do you spot/bleed between periods?

89. If so, what is the color?

90. Are you in menopause?

91. When did you go into menopause?

92. Do you have hot flashes?

93. Has there been any bleeding since you were fully in menopause?

94. Are you pregnant?

95. Are you breastfeeding?

Questions #96 - #102 Are For Male Respondents Only. Female Respondents Please Skip #96 - #102

96. Do you experience premature ejaculation?

97. When did it begin?

98. Do you experience a weak erection?

99. When did it begin?

100. Do you have impotence?

101. When did it begin?

102. What is your libido on a scale of 1-10 with 1 being very low libido and 10 being excessive libido?