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Consultation Form
Please fill out this comprehensive form to help us better understand your health needs.
Personal Information
How did you hear about us?
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Name
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Address
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Gender (How do you identify?)
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Phone
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Emergency Contact
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Health & Lifestyle Information
How many times per week are you physically active?
Which types of activities?
How many ounces of water do you drink daily?
What type of water do you drink daily?
Select Water Type
Tap Water
Spring Water
Distilled Water
How many digestive enzymes daily?
How many breathing exercises daily?
Dietary Information
Which do you consume daily?
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Soda Pop
Fast Food
Raw Fruit
Coffee
Milk
Meat
Smoking
White Flour
Raw Veggies
Alcoholic Beverages
Sugar Usage
Whole Grains
What type of foods do you crave?
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Salty
Chocolate
Sweets
Breads
Other
What are your favorite foods?
How much daily energy?
01 - Lowest
02
03
04
05 - Normal
06
07
08
09
10 - Highest Level
Medications & Supplements
List all current medications (include dosage and frequency):
List all supplements and vitamins you take:
Do you have any allergies to medications, foods, or environmental factors?
Do you have any current medical conditions or past medical history?
Acknowledgments & Disclaimers
I acknowledge that this telehealth consultation is not a substitute for in-person medical care and that I should seek immediate medical attention if I experience any emergency symptoms.
I understand that my personal health information will be kept confidential and used only for the purpose of providing healthcare services.
I certify that all information provided in this form is accurate and complete to the best of my knowledge.
I consent to receive healthcare services through telehealth technology and understand the potential risks and benefits.
I understand that The PureRx provides wellness consultation services and that any recommendations are not intended to diagnose, treat, cure, or prevent any disease.
I have read and agree to the terms and conditions of service.
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