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Health History Form

PERSONAL PROFILE

HEALTH PROFILE

FOR WOMEN

PAST HEALTH COMPLAINTS

Currently Taking

PAST MEDICAL EVENTS

Antibiotics:

Vaccinations:

Operations:

Accidents or Trauma:

Dental work other than cavities:

Other comments:

LIFESTYLE

What role does movement/excercise play in your life?

FOOD AND DIET

Favorite flavors (number 1 to 6, 1 being most liked)?

What were your usual meals as a child?

Whatʼs your diet like these days and in the past year ?

I understand that this consultation is a wellness consultation, which includes looking at diet and nutrition, exercise, emotional wellbeing, and may include recommendations for other healing modalities as necessary. I also understand that this consultation is informational and for educational purposes only. It is not intended to diagnose or cure any ailment or disease. I am fully responsible for how I apply the information received.
Payment is tendered for the time spent.
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