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How did you hear about us?
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Do you use online scheduling?
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Share Medical information with Spouse/Family Member
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Spouse/ Family Member Name
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Where did you find us?
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Want access to online portal?
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Occupation:
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Your Pharmacy:
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Do you smoke?
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Supplements
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Do you drink alcohol?
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Chief Complaint
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Amount:
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History of Present Illness
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Do you use illicit drugs?
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Cosmetic procedures in past:
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On any mood altering/anti-depression medication
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Surgical History
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Take Coumadin/daily Aspirin/blood thinners?
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Past Medical History
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Other Factors That Could Affect your Treatment
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Family History
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Diet
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Food allergies/sensitivities
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Sleep pattern
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Energy
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Exercise
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When was the date of your last menstrual period?
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Are you menopausal?
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Are you nursing?
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Are you pregnant?
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Trying to become pregnant?
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