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Name (First Name, Last Name)
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Birthdate (mm/dd/yyyy)
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Current weight:
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Goal weight:
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Address (Street Address, City, State / Province, Postal / Zip Code)
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Email
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Phone
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Who referred you to our ChiroThin program?
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Are you currently breast feeding, have active cancer, or cholecystitis?
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Do you experience any of the following?
• • •
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Are you on medications? If so, what are they for?
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Why do you currently want to lose weight?
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How long have you struggled with your weight?
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Have you tried other weight loss plans? If so, which one?
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What were your results?
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How long did you keep the weight off?
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Do you currently take nutritional supplementation? (Please note that if you take EFA's, you will need to discontinue while on this program.)
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Are there any other health concerns you would like us to know about?
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ChiroThin Weight Loss Program Informed Consent and Release of Liability
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Signature
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Date Signed (mm-dd-yyyy)
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ChiroThin Weight Loss Program Patient Declaration
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Signature
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Date Signed (mm-dd-yyyy)
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