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Height
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Weight (lbs)
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Where did you find us?
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Comments
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Occupation
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Working?
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Which specialists do you see?
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Who referred you?
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Anything special we need to know
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Married
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Single
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# of children
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How often you exercise?
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Level of overall health (1-10)
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Treatments tried before
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Vitamins & herbal supplements
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How long affected by condition
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Here for what health issue?
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What is diagnosis by MD?
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