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Please list areas of your life in which you would like to improve your health, ease or well-being

Briefly, what do you feel are some of the causes of the above difficulties?

Are you currently under the care of a physician? If so, who, and for what condition(s)?

List all current medications, prescribed or otherwise, including vitamins & supplements

o Surgeries & major physical or emotional traumas including dental, tonsils, appendix etc. use back if needed

patient name - new patient form