Intake Form
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| Name: ______________________ | Date of birth: ________________ |
| Address: |
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| Phone #:________________(h) | _____________________(w) |
| E-mail address: |
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| Main health concern: |
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| Blood type: ______(O, B, A, AB) | Hand (right or left): _______ |
| List supplements currently taking: |
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| List any medications currently taking: |
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| List any food sensitivities or cravings or other allergies: |
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| How much water do you drink per day? |
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| Describe any sleeping problems: |
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| Type of regular exercise? |
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| Other therapies currently used on a regular basis: |
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