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Intake Form

Please complete and submit. Thank you!

Gender
Health History
Family History
General
Do you snore?
Do you remember your dreams?
Do you grind your teeth?
Do you have nightmares?
Do you have restless legs (RLS)?
Do you have night sweats?
Have you had any labs done recently? If yes, please attach or send to me
Diet History
Pain Questionnaire
Symptom Survey
Check the symptom(s) if you are currently experiencing it, common occurrence, or have in the last 3 months
General
Mouth/Throat
Ears
Eyes
Nose/Sinus
Neck
Skin
Urinary
Muscles & Joints
Respiratory
Neurologic
Gastrointestinal
Hematologic
Psychological
Endocrine
Cardiac/Vascular
Sexual/Hormonal
For Females:
Sexual/Hormonal
Child form difference
Is he or she on a specific diet or nutrition program list

Thanks for submitting!

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