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Health History Form

Health History Form

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31Questions
  • 1
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  • 2
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  • 3
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  • 4
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  • 5
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  • 6
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  • 7
    What is your preferred video conferencing platform for your appointment?
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  • 8
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  • 9
    Goal weight & Current weight
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  • 10
    What goals would you like to achieve?
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  • 11
    What have you found challenging previously?
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  • 12
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  • 13
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  • 14
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  • 15
    What are you thoughts about this statement?
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  • 16
    Do you suffer from any of the following?
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  • 17
    Do you have any cravings or blood sugar issues?
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  • 18
    Where is your energy at?
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  • 19
    How is your sleep? How many hours of sleep do you generally get a night? Any of the following issues with waking or sleep depth?
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  • 20
    Do you have any allergies?
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  • 21
    How many times do you go to the bathroom for a bowel movement? Do you suffer from any of the ailments listed?
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  • 22
    Do you suffer from any of the following?
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  • 23
    Do you have a thyroid disorder?
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  • 24
    How is your mood?
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  • 25
    How much coffee do you drink?
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  • 26
    How much alcohol do you drink?
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  • 27
    Do you take any medications?
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  • 28
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  • 29
    Do you suffer any of the following symptoms before or during your cycle?
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  • 30
    How many days do you have menstruation for? What is the flow like? Do you suffer from any of the ailments listed?
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  • 31
    Do you suffer from any of the following?
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