Consultations Forms
Please fill out this form as accurately as possible and click submit that we can most appropriately address your health needs. You must answer all required questions marked by an asterisk (*) before submitting the page. The confidentiality of your health information is protected under the Health Insurance Portability and Accountability Act (HIPAA).
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First Name *
Last Name *
Your Age *
Gender *
Height (In Inches) *
Weight (in pounds) *
Country *
City *
Cellphone Number *
Email *
1.What do you hope to accomplish?
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2.Are you suffering mostly from mental /emotional issues? If Yes, please check one or more.

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3.Are you suffering mostly from the Physical issues? If Yes, please check one or more.

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4-Please write up to 5 symptoms which you are suffering the most.
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5-How confident are you in your ability to improve your nutrition habits?
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6-What barriers, if any, stand in the way of you achieving your nutritional goals?

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7-How often do you eat out?
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8-Are you on a special diets such as any listed below?

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9-Are you taking one or more Prescription drugs and Medication for your specific conditions and would like to switch to Herbal Medicine as an alternative to your medication?  
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Please list all prescription medication you use. Include those which you may only use occasionally such as  inhalers, eye drops, nose drops.
10-How did you hear about us?

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  Full name of the person who referred you to us  
You agree that Our products are not intended to diagnose, treat and cure or prevent disease. Information provided by DoctorReza Website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. Any information given is intended as a sharing of knowledge and information from scientific world literature. You are encouraged to make your own health care decisions based upon your own research of the subject and in partnership with a qualified healthcare professional. 
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