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Full name.........................................................................Age............................ Address............................................................................................................... ............................................................................................................................... Contact numbers............................................................................................... E-mail................................................................................................................... Recommended by............................................................................................. HEALTH BACKGROUND: Present state of health...................................................................................... Present medical treatment.............................................................................. Present orthodox medication.......................................................................... ............................................................................................................................... LIFESTYLE: Family situation (children/partner).................................................................. Occupation/position........................................................................................... What did you eat yesterday, and please be totally honest: Breakfast............................................................................................................... Snacks................................................................................................................... Lunch...................................................................................................................... Evening meal...................................................................................................... What makes you feel stressed at the moment?.......................................... ............................................................................................................................... What helps you relax?....................................................................................... MEDICAL HISTORY: List all surgical operations, serious illnesses and any significant injuries/ accidents you have had.................................................................................... ............................................................................................................................... List any emotional traumas that you feel may be significant..................... ............................................................................................................................... Please now list any symptoms that you suffer with at present ................ ................................................................................................................................ ................................................................................................................................ ................................................................................................................................ What would you like to be treated for first?................................................... .............................................................................................................................. Please read and sign the following: Fees are due at the end of each session, and nutritional supplements are charged seperately, and a fee will be charged if at least 24 hours is not given for rescheduled or cancelled appointments. I accept responsibility for my own health and well-being, and for participating in the methods, treatments and nutritional suggestions made during my treatment sessions. Signed:.............................................................Date.......................................
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