Health History

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Name(Required)
First Last
Best contact phone number(Required)
Best email(Required)
Date of Birth(Required)
MM slash DD slash YYYY
Age
Injuries / Past / Present(Required)
If none, type "None"
Medical Issues / Surgeries / Medications(Required)
If none, type "None"
Current Activity Level(Required)
Please list any chronic issues(Required)
What other forms of treatment have you tried?
Please list any supplements you consume and why:(Required)
Any other information you would like to share prior to your first session?
Signature(Required)
Signature Date
MM slash DD slash YYYY
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Comments
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