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For CLINIC visits, click this button
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For TO GO visits, click this button
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Please tell us why you're here
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How did you find out about the Remedy Room?
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Allergies to Medicine?
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List Meds You're Allergic To
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List of Prescription Medications
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Medicine continued.
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Past Medical History/Diagnoses Given
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Mom and Dad Past Medical Problems?
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Please list any Surgeries you've had
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Do you Smoke Cigarettes? How Much? How Often?
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Do you use vape products?
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Drink Alcohol? How Much? How Often?
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Marital Status
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Number of Children/Ages
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Number of Children
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Are you pregnant or nursing?
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What type of work are you in?
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When was last Bloodwork drawn?
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Have you eaten today?
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If yes, what time did you eat and what did you eat?
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Please tell us why you're here
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How did you find out about the Remedy Room?
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Allergies to Medicine?
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List Meds You're Allergic To
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List of Prescription Medications
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Past Medical History/Diagnoses Given
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Please list any Surgeries you've had
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Are you pregnant or nursing?
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Lung Disease (COPD?)
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Kidney Disease/Abnormal BUN/Cr?
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History of Liver Disease?
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Lung Disease (COPD?)
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Kidney Disease/Abnormal BUN/Cr?
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History of Liver Disease?
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For O SHOT visits, please click this button
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P SHOT (questions are for the LAST 6 MONTHS)
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Leak urine when you cough or sneeze?
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Confidence to keep erection
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Leak urine when you bend down or lift something?
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Time your erections are hard enough for penetration
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Leak urine when you walk quickly, jog, or exercise?
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Able to maintain erection after penetration
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Leak urine while undressing to use the restroom?
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Difficulty maintaining erection to completion of sex
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Urgency causing leakage before reaching the toilet
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How often was sexual intercourse satisfactory?
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Rush to the bathroom due to urgency
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For CHELATION visits, click this button
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For HIGH DOSE C visits, click this button
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General
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Neuro/Misc
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Symptoms
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Symptoms
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Eyes/Ears/Nose/Throat
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Heart/Lungs/Vascular
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Symptoms
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Symptoms
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Kidneys
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GI
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Symptoms
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Symptoms
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Other
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Symptoms/Diagnoses
• • •
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Exposure History
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Select which ones you have had exposures to
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Hospital/Oncologist Name + Phone #
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What type of cancer do you have?
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When were you first diagnosed?
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What stage is your cancer?
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Has your cancer spread? If so, where?
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Dates/Result of most recent scans and lab
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Treatments/Surgeries so far and results?
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Any side effects currently from treatment?
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EBOO Intake
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Have you ever had Ozone before? When and Where?
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Did you have any reactions to ozone in the past?
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Do you have a history of thick blood?
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Do you take photo active medication?
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List of Medications or Supplements you are taking:
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Do you have a drug or medication allergy?
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Do you smoke tobacco or cannabis?
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Are you allergic to heparin?
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What are your goals for today's EBOO treatment?
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Are you currently pregnant?
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Hypertension
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Congestive heart failure
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Severe Anemia
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Active Seizures
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Allergy to essential oils
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Cirrhosis
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Low Platelets
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Thyrotoxicosis
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Hyperthyroidism (Graves Ds)
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Constipation
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Heart condition
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Aneurysm
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Do you take IRON/Copper?
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Renal Insufficiency
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Parasitic infection
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RA/AS. Autoimmune Lyme or cancer
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Hemophilia or Blood disorder
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Do you have low G6PD
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EBOO Consent
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You are aware of and specifically understand that the Food and Drug Administration has not approved the Ozone-Oxygen mixture to be administered as a method of treating, curing, or preventing disease.
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You voluntarily agree to get ozone therapy treatment. No promises have been made to you or implied by the Physician or Nurse regarding the outcome of this treatment.
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I agree to hold the practitioner and The Remedy Room staff harmless. I will not blame them or hold them responsible in the event that EBOO therapy does not help me or if I have a problem/harmful reaction whatsoever relating to my therapy.
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I understand that I will be charged for any appointments not cancelled at least 24 hours in advance. I understand there are no refunds under any circumstances.
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Your signature is necessary in order to proceed with the EBOO. The affixing of your signature to this document demonstrates your volition and free choice in choosing as a health aid at my own will and as my right to try.
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