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Middlesex Spine & Sport Clinic www.middlesexspineandsportclinic.com Dr. Begin Hisashi, ND www.totalhealthnd.com Naturopathic Intake Form Please answer the following questions to the best of your knowledge.
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Start by entering your personal information, such as your name, address, and contact details.
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Provide your medical history, including any previous illnesses or injuries, chronic conditions, and surgeries you have undergone.
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Indicate any current medications you are taking, including prescription drugs, over-the-counter medications, and supplements.
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Answer questions about your lifestyle habits, such as smoking, alcohol consumption, exercise routine, and dietary preferences.
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Provide details about your family medical history, including any genetic conditions or diseases that run in your family.
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Mention any allergies or sensitivities you have to medications, foods, or environmental factors.
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If applicable, fill out sections related to your mental health, including any history of anxiety, depression, or other psychological disorders.
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Include information about your reproductive health, such as menstrual cycle, pregnancy history, and contraceptive methods used.
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If you have any specific concerns or symptoms, make sure to mention them in the appropriate sections of the form.
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Who needs total health intake formdoc:

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Total health intake formdoc is a document that gathers information about an individual's overall health history, including any medical conditions, medications, and allergies.
Total health intake formdoc is typically required to be filled out by patients when visiting a healthcare provider or facility for the first time.
Total health intake formdoc can usually be filled out by hand or electronically, providing detailed information about the individual's health status and medical history.
The purpose of total health intake formdoc is to provide healthcare providers with essential information about a patient's health background, allowing them to deliver appropriate care.
Information such as current medical conditions, past surgeries, medications, allergies, family medical history, and lifestyle habits are commonly reported on total health intake formdoc.
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