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Health Intake
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Name _____________________________________ Date
_________________
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" X " if a current issue or
need, "O" if a significant old
problem that’s mended, “?”
if not sure
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Check box
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MUSCULOSKELETAL
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Check box
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SYSTEMIC (cont.)
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1
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Jaw
area
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35
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Lymphatic
Drainage
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2
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Neck
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36
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Nervous
System
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3
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Shoulder
pain or restriction
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37
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Osteoporosis
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4
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Pectoral
muscle pain
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38
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Reynaud’s
Syndrome
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5
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Upper
arm
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39
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Sleep
problems
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6
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Elbow
or Forearm
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40
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Skin
condition
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7
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Hands,
wrists and/or thumbs
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41
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Swelling
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8
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Back -
Middle
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42
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Trembling
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9
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Chest
pain or congestion
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HEAD
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10
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Loins (above hips)
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43
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Bell’s
Palsy
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11
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Back -
Lower
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44
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Dizziness
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12
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Walking
problems
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45
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Ear -
infections, deafness, tinnitus
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13
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Hips
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46
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Eye
and sight problems
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14
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Sacrum
(spine above coccyx)
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47
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Hair
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15
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Coccyx (tailbone)
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48
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Headaches
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16
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Sciatic
nerve pain
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49
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Migraines
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17
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Hernia
- Inguinal
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50
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Nose,
palate
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18
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Groin
pain
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51
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Sinus
conditions
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19
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Restless
leg syndrome
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52
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Teeth
- grinding, crowding
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20
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Leg
cramps
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53
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Thyroid
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21
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Hamstrings
or Quads
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54
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Vertigo
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22
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Knees
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REPRODUCTIVE /
URINARY
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23
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Calf
or shin splints
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55
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Bladder
infections
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24
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Ankles
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56
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Breast
pain, cysts, mastectomy
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25
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Feet
and Toes
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57
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Incontinence
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SYSTEMIC
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58
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Conception
- series
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26
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A.D.D.
or A.D.H.D
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59
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Uterine
or ovarian
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27
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Arthritis
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60
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PMS
and menstrual symptoms
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28
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Bursitis
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61
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Pregnancy
- Due ____,_____,_____
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29
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Chronic
Fatigue Syndrome
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62
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Pregnancy
- during childbirth
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30
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Diabetes
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63
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Pregnancy
- post partum
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31
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Dyslexia
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64
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Menopausal
/ premenopausal
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32
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Endocrine
/ Hormonal
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65
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Prostate
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33
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Fibromyalgia
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66
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Sexual
organs Female or Male
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34
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Immune
and Endocrine System
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Page 2 of
intake FORM
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Check box
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CIRCULATORY
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Check box
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RESPIRATORY
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67
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Angina
pain
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86
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Allergies
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68
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Blood
impurities
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87
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Lungs
– Asthma, Bronchitis, etc.
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69
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Blood
Pressure
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88
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Colds
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70
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Cerebral
Hemorrhage / Stroke
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89
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Cough
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71
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Circulation
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90
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Diaphragm
pain / Hiatal hernia
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72
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Fever
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91
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Hay
fever
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73
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Heart
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92
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Pneumonia
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74
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Kidney
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93
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Sore
throat
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75
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Varicose
Veins
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SPIRIT
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DIGESTIVE
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94
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Depression
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76
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Abdominal
pain
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95
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Emotional
Overload
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77
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Constipation
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96
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Energy
Stimulant
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78
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Diarrhea,
Hemorrhoids
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97
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Mental
Clarity
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79
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Diverticulitis
/ IBS / Crohn’s
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98
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Stress
level __high, __med, ___low
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80
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Gall
Bladder
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99
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Meridian or Chakra specific
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81
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Ileocecal
valve
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FOR CHILDREN
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82
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Liver
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100
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Colicy
baby
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83
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Indigestion,
heartburn, nausea, bloating, ulcers, flatulence, etc.
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101
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Bed
Wetting - Series
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84
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Pancreas
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102
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other issues - add below
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85
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Weight
issues
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Health intake form 2010
Right click Icon then download to fill out and print
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