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Consultation Form
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Personal Information
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First
name *
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Last
name *
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Street
address
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City
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State/Province
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Zip/Postal
Code
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Country
*
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Phone
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E-mail
*
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Gender
*
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Age
*
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Height
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Cms
Or
Ft
Inch
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Weight
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Kg
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Profession
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Present
complaints *
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History
of present illness *
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Past
history (Other major diseases) *
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Habits
;
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Smoking
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Alcohol
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Has
any one had this problem in your family?
*
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Usual
food habits; *
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Treatment
History (Including the Diagnosis)*
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Menstrual
cycle (Females) *
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Digestive
capacity *
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Bowel
Movements*
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Number
of Bowel movements/day*
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Urinary
complaints (If any)*
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* Important details
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