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| First name * |
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| Last name |
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| Birth Date |
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| E-mail Address * |
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| Address |
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| Phone * |
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| What are your primary health concerns? * |
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| Are you willing to make changes to improve your health? |
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| In the last year, what steps have you taken to improve your health? |
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List anything you are currently doing that you
know is unhealthy? ie smoking, working nights etc. |
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| How many hours a night do you sleep? |
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| When do you go to bed? |
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| Do you exercise? |
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| If so what type? |
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How often do you have a bowel movement?
(Please be frank, this is a critical issue) * |
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| How much water do you drink per day? |
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| How much alcohol do you consume in a week or a month? |
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| How much TV do you watch in a week? |
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| Are you a vegetarian? |
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| Are you sensitive to cigarette smoke, perfume or car exhaust? |
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| Do you have any allergies? If so: To what? |
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| Have you ever seen a Natural Health Professional before? ie: Chiropractor, Acupuncturist, etc |
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| If so, what type? |
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| List any natural supplements you are currently taking * |
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| Are you currently seeing an MD or a DO? |
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| Do you have a diagnosis? If so, What? |
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| List any medications you are currently taking * |
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| Are you comfortable praying out loud? |
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| Do you have a personal relationship with Jesus Christ? |
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| Are you wearing a pace-maker? |
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| Females only: Are you pregnant? |
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| Is there anything else you would like me to know? |
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| On a scale of 1 to 10 with 1 being I feel awful, couldn’t be any worse, and 10 being feel terrific, couldn’t be better, rate the following: |
| Sleep* |
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Pain * |
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Energy * |
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| Mood* |
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Digestion* |
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