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Your Wellness Biography – Your Labwork
Name
*
First
Last
Email
*
Phone
*
Arthritis
Self
Parent
Grandparent
Sibling
Allergies/sinus
Self
Parent
Grandparent
Sibling
Cancer/Type
Self
Parent
Grandparent
Sibling
Diabetes
Self
Parent
Grandparent
Sibling
Heart disease
Self
Parent
Grandparent
Sibling
Thyroid disorder
Self
Parent
Grandparent
Sibling
Other
Self
Parent
Grandparent
Sibling
Gastro disease
Self
Parent
Grandparent
Sibling
Women
Last Pap
Date Format: MM slash DD slash YYYY
Mammogram
Date Format: MM slash DD slash YYYY
Menses
Date Format: MM slash DD slash YYYY
DEXA
Date Format: MM slash DD slash YYYY
Colonoscopy
Date Format: MM slash DD slash YYYY
Hysterectomy
Yes
No
Men
Last Digital Rectal Exam - Prostate health
Date Format: MM slash DD slash YYYY
Colonoscopy
Date Format: MM slash DD slash YYYY
Drug or Food Allergies
Please list all current prescription medications, over the counter meds, herbs and dietary supplements you take:
Medication/ Supplements
Dosage
Purpose
How long have you taken it
Side Effects
To what extent are you open and willing to make changes in your lifestyle and diet?
Not Open to Change
Somewhat Open to Change
Very Open to Change
Context of Care Review
What is your expectation of Integrative Health?
Whom or What helps you daily?
What is holding you back?
What do you love to do?
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