dvinemedspa
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Sex
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In case of emergency please contact:
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How did you hear about us?
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Internet
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What are your main complaints? (Please check all that apply)
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Fatigue or low energy
Stress
Poor diet due to busy lifestyle
Brain fog or trouble concentrating
Low mood or depression
Cold or flu symptoms
Dull or dry skin
Malabsorption issues
Intense workout regime
Other:
Which statements best describe why you are here today? (Please check all that apply)
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I want to have more energy and feel better overall
I want to do everything I can to nourish my body
I want to do everything I can to enhance my weight loss efforts
I want to prevent getting sick
I want to recover quickly from my surgery or illness
I want to slow the aging process
I want to feel and look younger
I want to have smoother, brighter and more vibrant skin
I want to cleanse my body of toxins
I want to recover quickly from a hangover
I want to improve my workouts
Other:
Are you pregnant or breastfeeding?
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Yes
No
Date of last chemistry screen or other lab testing:
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Have you ever been told that you have an electrolyte imbalance or other abnormal labs? (Please check all that apply)
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Hypermagnesemia (High magnesium levels)
Hypercalcemia (High calcium levels)
Hypokalemia (Low potassium levels)
Hemochromatosis (High iron levels)
Are you a diabetic?
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Yes
No
Are you a smoker?
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Yes
No
If yes, how much do you smoke?
How many alcoholic drinks do you consume in a week?
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Do you use any recreational drugs?
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Yes
No
If Yes, which ones and how often?
Please list everything you are currently taking: Prescription Medications – Strength – Frequency-Condition being treated
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Over the Counter Drugs – Strength – Frequency – Condition being treated
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TextVitamins and Other Supplements – Strength – Frequency – Condition being treated
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Do you take Digoxin (Lanoxin) for a heart problem?
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Yes
No
Do you take any diuretics or water pills?
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Yes
No
If Yes, please list:
CheckboxesDo you take any steroids, i.e. Prednisone?
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Yes
No
If Yes, please list:
Do you have any medication or food allergies?
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Yes
No
If Yes, please list:
Do you have any of the following conditions? (Please check all that apply)
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Blood pressure problems (High or low)
Heart Problems
Stroke or “mini-stroke”
Kidney Problems
Kidney Stones
Asthma
Sickle Cell Anemia
G6PD Deficiency
Sarcoidosis
Parathyroid problems (High levels)
List any other medical conditions you have (not mentioned above):
List of all surgical procedures you’ve had with approximate dates:
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Is there anything else you’d like the nurse and physician to know?
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