Personal Information
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- Spouse
- Parents
- Children
- Friends
- Alone
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Please choose
- Single
- Married
- Widowed
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WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.
Health Concerns - Please list your health concerns according to their severity
Rate of severity
- 1 = mild
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 = severe
- No elements found. Consider changing the search query.
- List is empty.
Rate of severity
- 1 = mild
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 = severe
- No elements found. Consider changing the search query.
- List is empty.
Rate of severity
- 1 = mild
- 2
- 3
- 4
- 5
- 6
- 7
- 2
- 9
- 10 = severe
- No elements found. Consider changing the search query.
- List is empty.
Provocation/Palliation
Quality
Region/Radiation
Other doctors you have seen for this condition:
Doctor's details
Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)
Is this condition interfering with any of the following:
