Contact Reflex Analysis – Designed Clinical Nutritional Evaluation
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Best time to call: Select Your Option Early Morning Noon Early Afternoon Late Afternoon Early Evening
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* Major complaint:
* Secondary complaint:
* Past history: Surgeries, illnesses, other conditions:
* Medications: (now taking):
* Supplements: (presently taking):
Pregnant or nursing: Yes No
* Treatment modalities presently utilizing: E.g. acupuncture, chiropractic, chelation therapy, other:
* Specific allergies: Please list, as well as allergies to specific medications:
Please mark diet: Vegan - Vegetarian Lacto-intolerant Gluten-intolerant Meat eater Other
* If "other" please specify:
* Any stints, implant surgeries, metal plates, screws, mesh, staples, pacemakers, transplant surgeries:
* Last blood test (when):
* Abnormal findings (please list -if any):
* Last mammography, pelvic exam including pap smear (when):
* Last prostate exam:
Result: Normal Abnormal
* Any history of sexually transmitted diseases: E.g. papilloma virus,etc.:
* Any history of genetic disorders:
* Any other items you would like to address:
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