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Diet and Exercise
How often do you exercise?
What forms of exercise do you get?
Do you consume a specific diet?
Yes
No
Please describe
Do you eat organic foods and hormone free meats commonly?
Yes
No
Stress and Toxins
Stress: On a scale of 1-10, with 10 being the highest, how would you rate your general stress level?
--None--
1
2
3
4
5
6
7
8
9
10
What causes you stress?
Do you have good stress coping mechanisms?
Yes
No
Do you have mercury (silver) filings in your mouth?
Yes
No
How long have you had your silver fillings?
Have you had exposure to any known toxins?
Yes
No
Please list
Have you ever been on long-term antibiotics?
Yes
No
List type and for how long
Tobacco, Alcohol, Drugs
Do You Drink Alcohol?
Yes
No
If Yes, 1) what kind of alcohol do you consume, and 2) what is your monthly consumption?
Do you use recreational drugs?
Yes
No
What type and how often?
Do you have a history of drug dependency?
Yes
No
What type and how often?
Do you currently use tobacco?
Yes
No
How Often And What Type?
Have you previously used tobacco?
Yes
No
How Often And What Type?
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