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Diagnosis sheet from the Chinese Herb Co. of San Francisco, California Chinese Herb Co. 1914

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 DIAGNOSIS SHEET
CHINESE HERB CO., 121 SECOND STREET, SAN FRANCISCO, CALIFORNIA
4
>
Answer all of the following questions.   Give any additional information that you may think important on the back of.
this sheet.    All correspondence strictly confidential.    Remember you are not placing yourself under obligation to me either
by filling out this blank or by accepting my free treatment.    (If you send the names of any of your friends, please be sure
to use the space given below for that purpose.)
Your   name. '. .V «. .Post  Office.
County
.State Street and No.
.R. F. D. No.
GENERAL   QUESTIONS
Age   Weight            Height.
Do you  have rheumatism	
Do you have scrofula or other blood poisons...._.J_!_.
Does your heart flutter or beat excitedly...,	
Do you have pains in the region pf your heart	
Do you have headache f	
What do you think was the cause of your disease.
What name do doctors give your disease	
Does   your   nose   discharge	
Is your sense of smell leaving   	
Is there a dropping into your throat 	
Do  you  cough	
Is "your sputum  (spit)  streaked with blood	
Do you have a burning sensation in the stomach...
Do you have sour risings (belching) 	
Have  you  bloating after  eating ,.	
Is  your  liver  torpid  	
Are you troubled w(th piles. ...
Do you have diarrhoea	
Are   you   constipated >  	
Do you vomit or have heart-burn.	
•Do you have pain in sniall of your back............
Do'.you have frequent desire to urinate.	
Do you have a bearing down  feeling
Do you have to rise at night to urinate	
Is  the  circulation   poor   (numbness)    	
Are you troubled with neuralgia	
Are you easily excited •	
Is your memory poor „	
Do you have hot flashes	
Do you  have melancholy  spells	
Have you any disease of a nature peculiar to your sex.
If so, describe fully on other side of this sheet	
ll5>
LIST OF  DISEASES.
NOTE—Draw a line around any of the following diseases
or symptoms you have.
Kidney Trouble
Bladder Trouble
Rheumatism
Lumbago
Eczema
Scrofula
Catarrh
Piles
Neuralgia
Diarrhoea
Constipation
Indigestion
Headache
Dizziness
Poor Circulation
Obesity
Heart Trouble
Impure Blood
Female Weakness
Torpid Liver
Malaria
Nervousness
Pimples
Asthma
Stomach Trouble
Chronic Cough
Anemia
Hay Fever
I KM PORTA NT I   Although I do not require you to do so, I will be greatly pleased if you will favor me by writing below the names
and address of your friends or neighbors who need medical treatment. Your name will not be mentioned when
I write to them.    I simply want to offer them a free treatment and a copy of my book
Don't Write YOUR Name Here—This Space is for the Names of OTHERS, who Need Treatment.
Name  Address,
Name  Address-
Name—  Address-
Name — *  Address-
Name •.....-  Address-
Name.   Address.
[OVER]
 You may describe here, or on a separate sheet of paper, any facts of interest regarding your case,   Simply explain your symp*
toms, or tell how you feel in your own words.   If you have any private diseases describe fully here.
LETTERS OF  PRAISE
MISERY    RELIEVED.
Chinese  Herb Co.,   San Francisco,  Cal.:
Dear Friend—I feel greatly benefitted by your trial treatment; also the
tablets and the herb tea. I feel thankful that I am relieved of so much
pain in my bowels and stomach. I have a good appetite and am getting
strong. Yours truly,
Curlew,   Wash. W.   W.   JOHNSON.
TORPID  LIVER—CONSTIPATION.
Chinese Herb Co.,  Ban Francisco,  Cal.:
Dear Sir—Inclosed find my report blank filled out. Your medicine has
done me lots of good. I kindly thank you for the improvement and
good you have done me. You are a wonderful man. You know exactly
what the human body needs. I will willingly recommend you to all that
are in need of good health. If I could keep well the way I feel now, I
would always feel grateful to you. Yours very truly,
Rockville,   Idaho. BARNEY   MALLOY.
RHEUMATISM.
Chinese Herb Co.,  San Francisco, Cal.:
Dear Sir—Your medicines which I received are having a good effect
on me. I do not feel the least bit nervous, as I did before. I sleep much
better. I do not feel the numbness in my hands as I used to. My appetite is much better. I am very much pleased with your treatment. I
remain your patient,
Napa,   Cal. JULIUS   BREMER.
FROM   OLD MEXICO.
Chinese Herb  Co.,   San   Francisco,   Cal.:
My Dear Doctor—You are great. You have done more for me in 10
days than 10 American doctors have done for me in 8 years. I feel 50
per cent, better than I did when I began your treatment, and after I
take your next treatment I am sure that I will be well. Then I will give
you a testimonial that you may publish if you want to, and I will recommend you to all I meet besides.    Your grateful and  true friend.
La  Cananea,   Sonora,  Mexico. ARCHIE  KELLY.
RHEUMATISM.
Chinese   Herb   Co.,   San  Francisco,   Cal.:
Dear Friend—Enclosed you will find the report blank which you asked
me to fill out and return to you when I had taken your-medicine for 10
days. As the stage line does not run on Sunday, it has delayed me in
sending it to you until one day later. The pains are all gone from my
stomach, but there is a slight pain in my chest of times yet. But it
seems to be growing lighter all t^e time, and I am beginning to feel like
a new man, and by the time I have taken all your medicine I think the
pain will be gone altogether. I can eat a good square meal now, but
before I took your remedies I could hardly eat anything. That is what
makes me gain in weight. I am feeling so much better that I am more
than grateful to you for your wonderful remedies and skill. I beg to be
yours respectfully.
Brownsville,   Cal. JAMES   LANG.
NERVE   EXHAUSTION.
Chinese jr_.erb Co., San Francisco, Cal.:
Dear Friend—Just received box by express; also I received medicine
by mail, and I am feeling fine now. You will always be my dear friend
and I cannot praise you enough. Where would I have been had I not
heard of you? Well, I will close for this time. Thanking you again for
your kindness,  as  ever your true friend,
1218 Baker Street, Kern City, Cal. MRS. A. W. HESS.
ILL   FOR  20  YEARS.
Chinese Herb Co., San Francisco, Cal.:
Dear Doctor—I have not had as good health for the past 20 years as
I have at present since taking your medicine. That bottle of tonic you
sent me—I never had anything so good in my life. I wish you would send
me some more. I had the bleeding piles once in a while and a weak
stomach that bothered me sometimes, but I am enjoying the best of
health  now.    Yours   sincerely,
Raymond, Wash. A. M. GRAVES.
A GRATEFUL PATIENT.
Chinese Herb Co.,  San Francisco,  Cal.:
Dear Friend—In answer to yours I would say that I have taken your
second treatment and am very grateful to you for the interest you have
taken in me. I am proud to say that your medicine has done me great
good in every way. I feel like a different man. My entire body is toned
up. I feel like work, sleep well, eat well—in fact, I am so much better
that I cannot express my thanks. I will write you again soon. I believe this course will make me a new man. With best wishes, I am
yours,
Paradise,   Texas. E.   G.   BARNETT.
BENEFITTED   IN   3  DAYS.
Chinese Herb Co.,  San Francisco,  Cal.
Dear Sir—Inclosed please find report sheet filled to the best of my
knowledge. I am getting along nicely. The third day that I used your
medicine I felt like a new man. My arms had been so sore I could
hardly do anything, but they are all right now. My legs got so tired
when I went up hill, but now I can go without any bother. I am longer
winded, too, now. I can work twice as long without stopping than before. Your medicine is all right. If I find anybody that needs help, I
will send you their names.    That is all I know of this time. Yours truly,
Baker   City,   Ore. J. M. SCHAFFER,
FEELS   LIKE   A   NEW   MAN.
Chinese Herb  Co.:
v. * Il,am1 glad t0 tel1 you J am improving in health fine. I have been in
had health for ten years. I believe and know you can cure me of my
disease, and I hope God will bless you. I have had kidney and bladder
trouble and sexual weakness for years, and in that I have suffered, and
I am glad to tell you I am feelinar this morning like a new man. I am
taking the medicine just as you directed.
Trusting to hear from you soon, with best wishes, I beg to remain
yours,
R. F. D. No. 3, Box 9, Boston, Ga.
MILO BRYANT.
[OVER]

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