Trial Course Reservation

（Please make sure to fill in items with ※）
※Name:     ※Age:
Sex: Female  Male
※Address:
※Telephone:
※When is the most convenient time to call you?
We will confirm your reservation by email or phone call
※E-Mail:
Message:

Please be reminded that Do-in classes in English are only available at Nihon Dokan International in Tokyo, Japan.
The following information helps us customize the Do-in Method for you. Please check/write in information concerning your health.


Which of the following are a problem for you?
1.Physical body
Sore shoulders
Back pain
Fatigue
Headache
Listlessness
Sore joints
Constipation
Menopause
Menstrual irregularities or cramps
Stomach, intestine & colon		 High blood pressure
Low blood pressure
Liver Ailment
Heart Ailment
Hemorrhoids
Poor circulation
Anemia
Dry eyes
Limited mobility in the joints
Others(Please explain)
2.Appearance
Overweight
Skin troubles
Pimples		 Too much body hair
Hair loss
Others(Please explain)
3.Mental/emotional
Irritability
Stress
Uneasiness		 Nervousness
Feeling down easily
Insomnia
Others(Please explain)
4.Have you had a serious accident or major illness?
Yes No
Please provide details;  Years   months ago
5.Have you had an operation ?
Yes  No
Please provide details;  Years   months ago 
6.Have you had any STDs (sexually transmitted diseases)?
Yes  No
Please provide details;  Years   months ago 
7.Sports, health practices, and methods of relaxation you have enjoyed:
Swimming
Running
Biking
Weight Lifting		 Aerobics
Walking/Hiking
Tennis
Golf		 Ski
Ch'i-kung
Judo
Tai Chi 		Kendo
Yoga
Karate
Meditation
Religious retreats
Others 
Which do you still practice? 
8.How did you find this site?
9.How did you hear of the Do-in Method?
Book The Taoist Road to Health - the Doin Method
Other Books about Do-in methods
Newspaper
Flyer
Signboard
From family or friends
OTHERS
  • *This questionnaire is only used within Nihon Dokan and not for any other use outside
  • *We carefully review new students at Nihon Dokan to ensure the methods taught will be used for healthful purposes. We are sorry if, from time to time, we refuse certain people's admission to our classes and programs. Thank you!

  

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