Lisa Fabry Nutrition & Yoga Therapy
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Date of birth
Phone number (inc country and area code)
Medical practitioner name and address
Do you have any current medically diagnosed conditions or injuries?
Describe what physical activity you currently do: type, frequency and duration.
What are your three main health goals?
Please list all medication you take, including prescribed drugs, over-the-counter medicines and supplements.
For each item, please include: daily dose, reason you are taking it and how long you have been taking it.
Have you ever experienced a hypersensitivity reaction to any medication or remedy?
Do you have any known allergies or sensitivities?