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Health Center

Intake Form

Do you smoke?
Do you experience headaches?
Do you suffer from fatigue?
Do you suffer from Allergies?
Do you suffer fro Varicose veins?
Do you suffer from flatulence(gas)?
How often do you have Bowel Movements?
Do you experience Body or Feet order ?
Do You experience Halitosis(bad breath)?
Do you suffer from Acne?
Do you have irregular or painful menstrations?
Do you suffer from reacurrent yeast infections?
Do you suffer from low back pain?
How would you rate your current health?
Are you commited to changing your life for the rest of your life?
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By pressing the send button you agree to be proactive with this program.Also by sending this is your signature,and by signing you understand this information is For educational purposes only.This information is not intended to diagnose, treat, cure, or prevent any disease.

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