CASE HISTORY FORM

IMMUNE SYSTEM Memory loss Blood clots Legs/feet/toes Frequent Colds/Flu ... Cups/day Do you drink tea? Yes / No How much? Cups/day Are you on a diet? Yes / No If yes, since when? Are you vegetarian? Yes / No If yes, since when? Are you vegan? Yes / No If yes, since when? APPOINTMENT BOOKING When is the best time for a consultation? Day: Time ... ................
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