Patient Medical History

We’d like to know more about you and your medical history. This way, we can develop a better treatment for you and don’t worry, all information is kept completely confidential.

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* 1. Tell us your full name:

Tell us your full name:

Your phone:

Your email:

Your Family Doctor name:

Your Family Doctor phone:

Your Family Doctor email:

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* 2. Are you feeling in good health?

Yes

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* 3. When was the last time you had a medical examination?

Less than 3 months

3 to 6 months

7 to 12 months

More than 12 months