Name______________________________________________________ Date_____________________________
e-mail____________________________________ Phone ___________________________________
Age__________________ Height_______________________ Weight______________________________
Occupation_______________________________________________
Chief Complaint (reason for seeking custom formula) . Please be specific about symptoms you are currently experiencing.
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When did this begin?
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Previous Surgeries, Hospitalizations, relevant health conditions
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Current Medications
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Allergies, Pain, Long term Ailments
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