Follow-Up
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Follow-Up
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249.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Demographics
Full Name
*
First Name
Last Name
Weight
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
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Which consultation would you like a follow-up on?
When did this consultation take place?
What specific item(s) would you like to focus on during the follow-up?
What outcome(s) are you looking to achieve from this follow-up?
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Medications
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Social History
Describe your diet
Describe your alcohol use
Do you smoke cigarettes or use tobacco products? If so, how often?
Describe your caffeine / energy drink / energy supplement habits
Describe your exercise habits
Describe your lifestyle
Describe your sleep habits
Describe your emotional state, moods, behaviors. What makes you happy, stressed, anxious?
How do you manage stress?
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Conclusion
What complaints / concerns do you have about your health and overall well-being?
What other questions or comments would you like to address?
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Appointment
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