Client Health History

  • What is their relationship?
  • Health History

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  • Including oral and topical prescriptions, over-the-counter herbs, vitamins and supplements.
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  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Details / Adverse Reactions? (if applicable)
  • Check all that apply.
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