HEALTH N.U.T.T. System Questionnaire
Name of the Patient/Client:
Date of Birth
/
Month
/
Day
Year
Date
Sex
Height
Weight
What is your blood type?
Have you ever tested positive or been exposed to COVID19?
If you have been exposed to COVID19, when?
Do you take the flu shot?
Do you smoke cigarettes or Marijuana?
Do you use any drugs or have in the past?
Do you eat meat, what kind?
Do you drink, if yes what?
Occupation
Currently employed
Are you feeling any kind of weakness/physical limitations problems?
Please circle all that apply
High Blood Pressure
Low Blood Pressure
Diabetes
Anemia
Pain
Arthritis
Sexual Dysfunction
Low Sex Drive
Depression Brain Disorder
List any family illnesses or genetic disorders:
Do you wear dentures or glasses?
Do you visit your doctor on a regular basis?
Are you taking any medications?
Yes
No
Please list all medications, including all vitamins.
Health N.U.T.T. System Disclaimer: Please advised that any herbal remedies or recommendations are not intended to treat or cure any diseases. Please provide your signature:
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