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Health Intake Form

Birthday
Was delivery long or difficult
no
yes
not sure
Were forceps or suction used?
no
yes
not sure
Were you breech?
no
yes
not sure
Were you cesarean?
no
yes
not sure
Did you have any major falls or accidents as a child?
no
yes
Do you smoke cigarettes?
no
yes
Do you drink alcohol?
no
yes
Do you take recreational or therapeutic/medical grade drugs?
no
yes
marijuana
psilocybin
ketamine
other
prefer not to answer
Do you take over the counter drugs?
no
yes
Have you been in any accidents?
no
yes
Do you get good quality/quantity sleep?
no
yes
Does this condition interfere with
On a scale of 1 - 10, how happy are you?
On a scale of 1 - 10, how much stress do you have in your life?
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