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Please fill out this form as completely as possible.
Be sure to print and fill out a diet diary from my website and bring it with you to your first visit.
Describe your main health concerns in order of importance to you. Click "add an item" (at the bottom right) for each new concern.
Please list any major trauma (mental, emotional or physical), injury, illness, accident or surgery that you have sustained. Click "add an item" (at the bottom right) to list each additional event.
Please list all current medications and supplements you take including prescription drugs, over the counter drugs, herbs, vitamins, minerals, homeopathics, etc. Click "add an item" at the bottom right for each new item.
Please indicate if any of your immediate biological family members suffer from, or have suffered from, any of the following conditions by checking all applicable boxes:
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