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Male City Street Address Date of Birth Female Zip Height Email Address State Weight Health History Do you have any dietary concerns or restrictions that may influence the dietary advice given? (high blood pressure, diabetes, heart conditions, religious restrictions, food sensitivities, etc.) Date: Do you have any chief complaints? What treatments have you tried so far? What Medications are you currently taking for this or any other condition? (OTC & Rx specify which meds fo.
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