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Last Name
Street Address 1
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City
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Date of Birth
Age
Height
Weight
Occupation
Drug Allergies
Seasonal Allergies
Pet Allergies
Alcohol Use?
How Much Alcohol?
Tobacco Use?
How Many Pks per day if Yest
Caffeine
How Much
Current Medications
Conditions or Diagnosis
Primary Dr's Name, Address, Phone & Fax
Do You Exercise
How Many Times per week
Increased Urinary Urge
Prostate Problems
Decreased Erections
Difficulty Concentrating
Increased Forgetfulness
Foggy Thinking
Tearful
Depressed
Mood Swings
Fluid Retention/Bloating
Stress
Anxious
Irritable
Nervous
Decreased Mental Sharpness
Morning Fatigue
Afternoon Fatigue
Evening Fatigue
Excessive Worry
Difficulty Falling Asleep
Difficulty Staying Asleep
Decreased Stamina
Diminished Motivation
Fibromyalgia
Ringing in the Ears
Allergies
Headaches/Migraines
Dizzy Spells
Sugar/Carb Cravings
Craving Food, Alcohol, Tobacco or Other
Poor Impulse Control
Obsessive Behavior (OCD)
Addictive Behavior
Constipation
Goiter
Cold Body Temperature
Hoarseness
Hair Dry or Brittle
Nails Breaking or Brittle
Slow Pulse Rate
Rapid Heartbeat
Heart Fluttering/Palpitations
Incontinence
Hot Flashes
Night Sweats
Infertility Concerns
Acne
Scalp Hair Loss
Weight Gain-Hips
Weight Gain Weaist
High Cholesterol
Elevated Triglycerides
Decreased Libido
Decreased Muscle Size/Tone
Decreased Flexibility
Burned Out Feeling
Sore Muscles
Increased Joint Pain
Neck or Back Pain
Bone Loss
Thinning Skin
Rapid Aging
Aches and Pains
Irritable Bowel Syndrome
Decreased Urine Flow
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