Name

Age

Gender

• Male

• Female

Phone number

Email

Do you have any chronic conditions or allergies?

If yes, please specify

Do you currently take any prescription medications?

If yes, please list

Do you smoke?

How often do you consume alcohol?

How often do you exercise?

How would you describe your diet?

How would you rate your stress level?

• Low

• Medium

• High

How would you rate your overall health?

Is there anything else you would like to share?

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