Do you have any of the following issues?
Irregular Heart Beat Hypertension (High Blood Pressure)
Medications: Please list name of medication and dosage
Have you started, stopped or changed medication or dosages within the last 3 months? If so, what
Are you planning to get pregnant in the next 6 months? Yes / No
Are you currently pregnant or nursing? Yes/No
Doyou take Contraceptive Pills? Yes / No How long have you taken them Year(s)
Are aware of having Diabetes? If so, what type?
What medications are you currently taking for your Diabetes?
Have you currently had or plan to take a PSA blood test for the screening of prostate cancer? Yes
Do you have an enlarged prostate, prostate cancer? Yes
Have you recently changed your diet?
Are you a vegetarian? Yes / No
Consent for Holistic Health Consultation
I agree to being evaluated and I understand I will first undergo a comprehensive preliminary evaluation by an experienced consultant. I further understand my results will vary. I acknowledge that it is my responsibility to inform Hair Resolution Center of Brooklyn, LLC of any changes in my health, no matter how slight.
I understand some general recommendations will be made based on the initial consultation.