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Your Name: |
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| Your Email: |
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| Daytime Phone: |
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Date of Birth : |
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Sex |
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 |
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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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