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Health Questionaire
Health Questionnaire:
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* Indicates required question
Email
*
Your email
Name:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Mobile:
*
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Age:
Your answer
How did you hear about Hydro Wellbeing?
*
Your answer
Describe your current health:
Your answer
What is your reason for treatment?
Your answer
Please list all medications you take:
Your answer
Is there a family history of intestinal problems?
*
Yes
No
If yes, Is there a family history of intestinal problems, please explain:
Your answer
My bowel movements are:
Spontaneous
Occur after eating
Straining/Painful
Incomplete feeling
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