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Reflective Body LLC Intake form

Reflective Body LLC is dedicated to provide holistic patient centric care in the states of Connecticut and New York. This is a CONFIDENTIAL questionnaire to help us determine an optimal treatment plan for you. 

Personal information

Sex:

Physician History

Have you seen a physician in the last year?

Please indicate any significant illnesses you have had:

Sexually Transmitted Diseases:

Please indicate the use and frequency of the following:

Coffee/Black tea
Tobacco
Water
Recreational drugs
Alcohol
Soda pop

Health complaints

How do you feel about the following areas of your life?

Symptom Survey

Do you experience any of these symptoms
Row 2
Please check boxes if any of the following statements are true:

For men

Symptoms related to prostate

Thanks for submitting!

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