General Patient Information Form
(Optional)
Patient Gender
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Male
Female
Patient Name
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First Name
Last Name
Patient Age
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Patient Weight (kg's)
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WhatsApp & Contact Number
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Patient Medical History
Drug or food allergies?
Have you ever had (Please check all that apply)
Anemia
Asthma
Arthritis
Cancer
Diabetes
Epilepsy Seizures
Gallstones
Heart Disease
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Ulcer Disease
Hepatitis
Kidney Disease
Liver Disease
Thyroid Problems
Tuberculosis
Bleeding Disorders
Lung Disease
Other illnesses:
Please list your Current Medications if taking
Healthy & Unhealthy Habits
Exercise
Never
1-2 days
3-4 days
5+ days
Eating following a diet
I have a loose diet
I have a strict diet
I don't have a diet plan
Alcohol Habit
I don't drink
I drink
Caffeine Consumption
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Your current Medical History for consultation.
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