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General Intake Form

Holistic Health Guardians / General Intake Form

General Intake Form

To better assist you please provide some General Information about yourself. 

1 Step 1
Sexpick one!
Frame Sizepick one, we don't judge.
Marital Statushelps us get to know you better
Chemical Exposurepick one!
Lifestyle / Occupationpick one!
Do You Smokepick one!
Are you currently taking any of the following medications?Select any that apply
Do you currently have or ever had any of the following conditions?Select any that apply
Have you ever had to abstain from any of the following?Select any that apply
Do you have any silver fillings?Dental amalgams
Have you been or are you undergoing psychological counceling?pick one!
Are you currently seeing a...?Select any that apply
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