Living Veda - Client History
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Phone Number *
Email *
Referred By *
Reason for Consultation *
What are your symptoms or concerns? How long have you had them? *
Occupation *
Do you enjoy your work? *
Rate level of job stress *
Low
High
Source of job stress *
Do you experience stress in any particular part of your body? *
Marital Status *
How many children at home? *
Pregnancies *
If in a relationship, are you happy? *
Family Life Stresses *
Medical History
Are you currently under a physician's care? *
Physician's Name
Last Physical Exam Date
MM
/
DD
/
YYYY
Exam Results
Height *
Weight *
What prescription drugs are you taking (including birth control)? *
What non-prescription drugs, medications, supplements, or recreational; drugs are you taking, have taken (including alcohol, tobacco, caffeine, marijuana)? *
What major illness or operations have you had in your life? *
Have you consistently experienced any of the following?
Has anyone in your family consistently experienced any of the following?
General Health Information
Do you have a healthy diet? *
Do you exercise? *
What type of exercise?
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