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          Patient Details


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          Address*                                             City*

                       


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          Fax                                                    Phone*

                     


          Best time to contact                           Preferred Date

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          Current Medical Conditions



          Do you take any food/vitamin supplements? If so, what?



          Do you smoke? If yes, how many per day?



          Exercise (what types and how often)



          How well do you sleep?

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          Average hours of sleep per night

           





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