Basic Goldberger's Basic Health Questionaire

Your Name: ______________________________________________________________
Your Email: ______________________________________________________________
Daytime Phone: ______________________________________________________________
Date of Birth : _________
Sex M __ F __
Race __________________________________________________
Weight (pounds) ________
Height ________
Specify any allergies

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For what health conditions are currently being treated? ______________________________________________________________
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What prescription medications are you currently taking? Please include strength and frequency. ______________________________________________________________
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Are you currently taking any herbal suppliments? ______________________________________________________________
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List any Vitamins you are taking. ______________________________________________________________
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What  over the counter medications are you currently taking? ______________________________________________________________
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Have you ever had an adverse reaction  in to any medications the past? If so, please specify. ______________________________________________________________
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