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How did you find us?
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Who referred you?
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Name of Primary Care Doctor:
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Do you exercise?
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If you do exercise, how often?
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What type of exercise(s)?
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Which specialists do you see?
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Do you work/hold a job?
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Name of Employer:
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Responsibilities at Work:
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Are you married?
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Do you consume alcohol?
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Do you smoke? Please indicate:
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Anything special we need to know:
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Do you use online scheduling?
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Want access to online portal?
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