Health History

Health History Form
Would you like your weight to be different?
Do you wake up at night?
Any pain, stiffness or swelling?
Constipation/Diarrhea/Gas?

For Females:

Are your periods regular?

What foods did you eat often as a child?

What is your food like these days?

Do you cook?

© Karen Mayo Enterprises | A Health & Wellness Company.  All rights reserved

600 Mamaroneck Avenue Suite 400, Harrison, NY 10528

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