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(Alpha Health Rx) Alpha Health & Nutrition Rx

Questionnaire

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Health Questionnaire (pdf)

Health Questionnaire

Name________________________________ Contact#_______________________

Address_______________________________ Today’s Date___________________

_____________________________________

_____________________________________

 

What is your Current Medical History?

 

 

What Symptoms do you currently have?

 

 

 

What areas of health would you like to have addressed or have help with?

 

Current Medications_______________________________________________________________________________________________________________________________________

Comments______________________________________________________________________________________________________________________________________

-----------------------------------To be completed by Consultant------------------------------------

Assessment

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Recommendations

________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________

 

PRIVACY STATEMENT: The privacy of your health information is protected. This organization will protect the privacy of your health information as required by law. Your private health information will not be disclosed to anyone other than you without your consent.

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