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Email
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Your email
Last Name
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Your answer
First Name
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Your answer
Date of birth
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MM
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DD
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YYYY
Address
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Your answer
Occupation
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Your answer
Phone
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Your answer
Emergency Contact
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Your answer
Family Physician’s Name
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Your answer
How did you hear about us?
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Web
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Doctor or other referral
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Current treatments, including medications
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Your answer
What is the reason for your visit?
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Please check those conditions, past or present, that apply to you:
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Heart disease
Stroke
Anemia
Anxiety
Diabetes
Sleep disturbances
Thyroid issues
High cholesterol
High/low blood pressure
Digestive issues
Disorders eating
Depression
Cancer
Food allergies/intolerances
Option 15
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