Health Questionnaire

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First Name

Last Name

Email Address

Phone Number

Age

Gender

Primary Health Complaint

Describe your symptoms, including frequency and duration.

When did they start?

Diet And Lifestyle

Do you smoke?


If yes, how many a day?

How many standard drinks do you consume per week?

How many times a week do you exercise? What sort of exercise/activity do you do?

How many times a week do you exercise? What sort of exercise/activity do you do?

Are you pregnant?


Are you breastfeeding?

Medical Conditions

Do you have any of the following?














Give details:

Medication History

Medications:

Supplements: