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Healthy Dome
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Intake form
Help us serve you better
Name
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Email address
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What is your age group?
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Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
What is your gender?
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Male
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What is your primary health concern?
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General health
Mental health
Chronic illness
Nutrition
Fitness
Weight management
Preventive care
Are you currently taking any medications?
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Yes
No
Do you have any allergies?
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Yes
No
If yes, please specify your allergies.
What is the best time for a consultation?
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Morning
Afternoon
Evening
How did you hear about us?
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Social media
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Please provide your phone number.
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