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Lifestyle Assessment
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Patient's Name:
*
First and last name
Your answer
Age:
Your answer
What is your email address?
Your answer
Any chronic condition (s)?
*
Select one or more
Heart Disease
Congestive Heart Failure
High Cholesterol
High Blood Pressure
Cancer
Type 2 Diabetes
Obesity
Autoimmune Disease
Gastrointestinal Disorders (Crohn's, Colitis, Constipation, GERD)
COPD
Asthma
Depression
Anxiety
Bone and Joint Disease (Arthritis, Osteoporosis, Gout)
Alzheimer's Disease or Dementia
Chronic Liver Disease
Chronic Kidney Disease
Polypharmacy (taking 5 or more medication)
No Chronic Disease
Other:
Required
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