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Intake Form
Personal Information
First name
Phone
Your email
Sex
Choose an option
Last name
Date of Birth
Marital Status:
Choose an option
Enter Height:
Enter Weight:
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
General Information
Do you use tobacco products?
YES
NO
Do you regularly use any cannabis products?
YES
NO
Do consume any alcohol?
YES
NO
Do you take any nutritional / natural supplements?
YES
NO
Do you have any allergies?
YES
NO
Do you have any medical conditions or diseases?
YES
NO
Do you currently take any prescriptions?
YES
NO
Medical History
Have you been told you have any of the following :
Ischemic heart disease/ Previous Heart attack
*
YES
NO
Ischemic heart disease/ Previous Heart attack
*
YES
NO
Atrial Fibrillation
*
YES
NO
Diabetes
*
YES
NO
COPD
*
YES
NO
Asthma
*
YES
NO
Hypertension
*
YES
NO
CVA/ Stroke / TIA or mini-stroke
*
YES
NO
Thyroid Problems
*
YES
NO
Arthritis
*
YES
NO
Depression
*
YES
NO
Anxiety
*
YES
NO
Other
Family History
Significant Family History
OVER-THE-COUNTER (OTC) PRODUCT USE
Please select relevant over the counter medications that you currently take.
Pain Reliever
Aspirin
Acetaminophen
Ibuprofen
Naproxen
Antacids (ie. Maalox)
Acid Blockers
Cough Suppressants
Combination (ie. cough + cold)
Sleep Aids (ie. Melatonin)
Antidiarrheals (ie. Pepto-Bismol)
Laxatives (ie. Docusate or Bisacodyl)
Diet Aid / Weight Loss Products
Antihistamines
Decongestants
Family Doctor
Doctor Phone
I give consent to my health care information
Your Signature
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Thanks for your trust!
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