Consultation

Your name *

Your email *

Phone Number *

What is your main concern today? *
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Have you experienced this problem before? *
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How long have you been experiencing this issue? *
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Does the problem affect your daily life or work? *
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Have you tried any remedies or treatments before? *
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Are you currently taking any medications? *
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Do you have any allergies or medical conditions? *
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Have you had any recent medical tests or procedures? *
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Are you experiencing any pain or discomfort? *
YesNo

Is there any swelling or redness? *
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Have you experienced any fever or chills? *
YesNo

Do you have any trouble sleeping? *
YesNo

Have you noticed any changes in your appetite or weight? *
YesNo

Do you have a family history of any medical conditions? *
YesNo

Are you currently pregnant or trying to conceive? *
YesNo

Have you recently travelled outside of the country? *
YesNo

Have you been exposed to anyone with a contagious illness? *
YesNo

Have you experienced any changes in your vision or hearing? *
YesNo

Do you have any difficulty with balance or coordination? *
YesNo

Have you experienced any chest pain or shortness of breath? *
YesNo

Have you noticed any changes in your bowel or bladder habits? *
YesNo

Do you have any skin issues or rashes? *
YesNo

Have you had any recent injuries or accidents? *
YesNo

Do you smoke or drink alcohol? *
YesNo

Do you exercise regularly? *
YesNo

Have you experienced any changes in your mood or mental health? *
YesNo

Do you have any concerns about your sexual health? *
YesNo

Have you experienced any changes in your menstrual cycle? *
YesNo

Are you currently using any contraception or family planning methods? *
YesNo

Have you experienced any changes in your energy level or fatigue? *
YesNo

Do you have any concerns about your immune system or autoimmune disorders? *
YesNo

Have you had any surgeries in the past? *
YesNo

Do you have any chronic medical conditions? *
YesNo

Are you currently seeing any other healthcare providers? *
YesNo

Are you interested in any alternative or complementary therapies? *
YesNo

Do you have any financial or insurance concerns related to your healthcare? *
YesNo

Have you experienced any changes in your hearing or taste? *
YesNo

Do you have any dental or oral health concerns? *
YesNo

Have you had any recent vaccinations or immunizations? *
YesNo

Are you interested in any preventive healthcare measures or screenings? *
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