Program Participant Intake & Consent

Program Participant Intake & Consent

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  • Program Participant Intake & Consent

  • for all programs under the guidance of Dr. Angela Cortal
  • General Information

  •  -
  • Medical History

  • Personal History

  • Diet and lifestyle

  • Let's get a current picture of your health

  •   No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago
    Fatigue
    Unexplained weight loss or gain
    Change in appetite
    Depressive symptoms
    Anxiety
    Mood swings
    Nervousness
    Addictive dependency
    Disordered Eating Pattern/Tendency
    Tension
    Lack of mental focus
    Thyroid problems
    Diabetes
    Blood sugar irregularities
    Excessive thirst or hunger
    Sugar cravings
    Abnormal hair growth
    Excessive perspiration
    Feeling excessively hot or cold
    Headache
    Lightheadednes
    Joint pain or stiffness
    Muscle weakness or soreness
    High blood pressure
    Heart murmur/palpitations
    Cold or pale extremities
    Asthma
    Short of breath
    Heartburn
    Abdominal discomfort after eating
    Nausea
    Abdominal bloating
    Blelching/gas
    Constipation
    Diarrhea
    Daily bowel movements
  • Clear
  • Should be Empty: