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Health Questionnaire

The form below provides me with pertinent information that will be used for our consultations.  It take about ten minutes to fill out.  Please be as accurate and descriptive as possible.  All client information is kept strictly confidential.

General Questions
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Family History
Habits
Eating Habits
Adrenal hypofunction
Digestive Tract
Small Intestine (Pancreas)
Gallbladder/ Liver
Ears
Emotions
Energy
Eyes
Heart
Hypoglycemia
Hypothyroid
Hyperthyroid
Joint / Muscle
Menstruation (females only)
Menopausal (females only)
Mind
Lungs
Nose
Pituitary Hypo
Pituitary Hyper
Prostate (males only)
Andropause (males only)
Skin
Weight
Enviromental toxins
Other
 

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