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HEALTH HISTORY
Name______________________________________________________________Date_________________Phones: (W)_________________(H)_________________(Fax)_______________(email)_____________________Address__________________________________________________________________ Zip_______________Referred by ___________________________________For___________________________________________Insurance__________________________________Hosp. only_____HMO_____PPO_____PPO+_____Full_____ VITAL STATISTICS
Date of Birth________________ Age________ Height_________ Weight__________ Desired Weight___________Gender ________ Blood Type_________ Race__________Ethnic Ancestry_______________________________Age of Puberty ________ # Children ________ Menstrual Cycle: # days ____________ Menopause Age _________ PURPOSE OF VISIT
Primary ____________________________________________________________________________________Secondary _________________________________________________________________________________ MEDICAL HISTORY
Infancy: Premature?________Breastfed? _______ How long? __________ Formula: Cow ____ Goat _____ Soy _____Childhood Diseases___________________________________________________________________________Teenage Diseases____________________________________________________________________________Adult Diseases________________________________________________________________________________________________________________________________________________________________________Family Diseases______________________________________________________________________________Injuries____________________________________________________________________________________Surgeries_____________________________________________________Complications___________________Allergies___________________________________________________________________________________Current Medications __________________________________________________________________________Past Medications_____________________________________________________________________________Primary Physician _________________________Diagnosis____________________________________________ Specialist Physician ________________________Diagnosis___________________________________________Other Therapists_____________________________________________________________________________ LIFESTYLE
Occupation_____________________________________________________________Long Hours?__________Major Life Stresses___________________________________________________________________________Travel Frequently____________________________Eat At Restaurants Frequently __________________________Exercise__________________________________________________________ Hours Per Week? ___________Sleep: Hours at Night__________Dreams About Health_____________________Nightmares__________________Fatigued-Drowsy?__________Daily Energy Peaks__________________Daily Energy Lows____________________Glasses_____Contact Lenses______ Strength ____________Tint_____________Eye Surgery________________Dental Disease or Surgery _____________________________________________Dentures__________________Water Source: Tap ________ Well ________ Filtered ________ Bottled ________Type Plumbing?_______________Drink Alcohol? _________ How Much? ______________________ How many years? ________Quit?____________ ____ Child -- Poor growth, short____ Teen -- Delayed puberty ____ Sodas, Alcohol, Cortisone, Diuretics DIET PATTERNS
DIGESTION
ALLERGY SYMPTOMS
____Sensitivity to light or soundMusculo-Skeletal FOODS EATEN
AMINO ACIDS
FATTY ACIDS
SACCHARIDES

Source: http://www.laurapower.com/intakeform.pdf

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Farm/Ranch - Food Safety & GAP Systems with Spanish Questions Company/Contact Information Audit Information Facility: DZB91 Agricola La Minita, S.P.R. de R.L.-El Audit# - Visit#: Audit Type: Address: Template Version: Contact: Auditor: Audit Start Time: Audit End Time: Commodities: Carrots,Cauliflower,Celery,Garlic,Lettuce,Pepper, Chili,Radicchio,S

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