Health Questionnaire

Primary Health Complaint

Diet and Lifestyle

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NoYes
NoYes
NoYes

Medical Conditions

Do you have any of the following?

YesNo

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

Medication History

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