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  • About Me
    • Integrative Nutrition Health Coach
  • Work with Me
    • Health Coach Services
    • My Approach
    • Forms >
      • Revisit Form
      • Confidential Health History Form
  • Contact
  • Blog
    • Health
    • Recipes

    Health History - Men

    PERSONAL INFORMATION

    SOCIAL INFORMATION

    HEALTH INFORMATION

    MEDICAL INFORMATION

    FOOD INFORMATION

    RATE THE SEVERITY OF EACH SYMPTOM YOU HAVE EXPERIENCED OVER THE PAST TWO YEARS.

    Symptom Questionnaire
    Use a 0 if you never have the symptom.
    Use a 1 if you occasionally have it and the effect is mild.
    Use a 2 if you occasionally have it and the effect is severe.
    Use a 3 if you frequently or consistently have it and the effect is mild
    Use a 4 if you frequently or consistently have it and the effect is severe.​
Submit
Pamela Schubloom, CHC, CPC, AADP
Certified Holistic Health Coach
pamela@brandnewdaywellness.com
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