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WEIGHT LOSS PATIENT FORM
Have you ever been treated for an emotional problem?
Yes
No
Are you currently taking any medication?
Yes
No
If you answered Yes to the above question, please explain what and why.
HABITS
Alcohol per day
Caffeine products per day
Do you use street drugs?
Yes
No
If you answered Yes to the above question, please say what kind.
Are you presently in any physical discomfort?
Yes
No
If you answered Yes to the above question, please say where.
Please check if you have or have had any of the following:
Cramps or numbness
Liver trouble
Heart trouble
Kidney trouble
Asthma
Tuberculosis
Eye trouble
Ear trouble
Blood disease
Have you ever been hypnotized?
Yes
No
If you answered Yes to the above question, please say why and explain the results.