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Page 1: acubyjewels.comacubyjewels.com/assets/Intake-Form.pdfChinese Organ Diagnostic Chart Please rate symptom severity 1 to 5 (5 being worst). Leave blank if N/A Liver/Gall Bladder Irritability

Page 2: acubyjewels.comacubyjewels.com/assets/Intake-Form.pdfChinese Organ Diagnostic Chart Please rate symptom severity 1 to 5 (5 being worst). Leave blank if N/A Liver/Gall Bladder Irritability

Page 3: acubyjewels.comacubyjewels.com/assets/Intake-Form.pdfChinese Organ Diagnostic Chart Please rate symptom severity 1 to 5 (5 being worst). Leave blank if N/A Liver/Gall Bladder Irritability

Page 4: acubyjewels.comacubyjewels.com/assets/Intake-Form.pdfChinese Organ Diagnostic Chart Please rate symptom severity 1 to 5 (5 being worst). Leave blank if N/A Liver/Gall Bladder Irritability

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