One's health and well-being are influenced by many different things, including lifestyle, family history, emotional health, and nutrition/eating habits. Please complete the following questionnaire to the best of your ability to give us an overall view of your general lifestyle and health habits.
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
I, First Name* Last Name* , Hereby authorize the use or disclosure of my health information from the listed health care practitioner as described below to the requesting practitioner.
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