Patient Intake Questionnaire
Current Herbs / Vitamins/ Homeopathy/ Supplements Dose Times / Day ... Children AIDS Alcoholism Allergies Alzheimer’s Anemia Arthritis Asthma Birth Defects Bleeding Disorder Breast Cancer Cancer Colon Cancer COPD Depression Diabetes Emphysema Epilepsy Glaucoma Heart Attack Heart Trouble High Blood Pressure IBS Kidney Disease Liver Disease Mental Illness Migraine Headaches … ................
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