Name:
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Email :
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Daytime Phone:
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Date of Birth :
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Sex
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M __ F __
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Race
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Weight
(pounds)
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Height
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Specify
any allergies or adverse reactions you have had to medication.
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Any health conditions that are currently being treated?
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Any
prescription medications are you currently taking? Please include strength and frequency
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What
over the counter medications are you currently taking? Please include strength and frequency
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What vitamins/herbal supplements are you currently taking? Please include name, strength and frequency.
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