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Consultation Form

Health Consultation

Please fill in the fields so that we have a better picture of your current state of health.

Or you can download the PDF document and you can send it to me at:


Please indicate if you have experienced any of the following health conditions:

What level of stress are you experiencing most recently?

How is regular Appetite?

How is Bowl movements?

How is sleeping quality?

Daily water Intake?

How does stress affect your life? 

Are you familiar with any of these words?

I the undersigned hereby declare that I have read and understood the medical and health questionnaire, and that all the answers to all the questions by myself: I declare that I have given full and correct information about my past and present medical condition.

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