| Name: |
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| Email: |
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| City: |
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| State: |
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| How often do you check your email? |
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| Work Phone: |
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| Home Phone: |
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| Cell Phone: |
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| Height: |
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| Weight: |
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| Date of birth: |
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| Weight 6 months ago: |
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| Weight 1 year ago: |
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| Would you like your weight to be different |
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| If yes, what? |
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| Relationship status |
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| Children |
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| Occupation |
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| Hours per week |
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| Please list your main health concerns: |
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| Please list any allergies: |
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| Other concerns: |
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| Any serious hospitalizations or injuries: |
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| If yes, please list: |
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| How is your mother's health? |
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| How is your father's health? |
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| What is your ancestry? |
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| What blood type are you? |
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| Do you sleep well? |
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| How many hours? |
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| Do you wake up at night? |
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| Why? |
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| Any pain, stiffness, or swelling? |
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| Please explain: |
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| Are your periods regular? |
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| How many days is your flow? |
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| How frequent? |
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| Painful or symptomatic? |
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| Please explain: |
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| Birth control history: |
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| Vaginal infections, reproductive concerns? |
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| Constipation, diarrhea or gas? |
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| Explain: |
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| Do you take any supplements or medication? |
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| Please list: |
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| Any healers, helpers, pets or therapies with which you are involved? |
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| Please list: |
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| What role do sports and exercise play in your life? |
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Below please list what foods you used to eat often as a child:
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| Breakfast: |
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| Lunch: |
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| Dinner: |
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| Snacks: |
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| Liquids: |
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Please list what foods you eat these days:
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| Breakfast: |
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| Lunch: |
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| Dinner: |
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| Snacks: |
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| Liquids: |
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| What percentage of your food is home cooked? |
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| What percentage is not? |
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| Where do you get the rest from? |
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| Do you crave sugar, coffee, or have any other major addictions? |
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| Anything else you would like to share? |
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