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Are you prepared to commit to a fairly restrictive diet for a 3 to 6 week timeframe to lose 1/2lb to 1lb per day?

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Patient Information and Medical History Form

CONTACT INFORMATION

PRIMARY PHYSICIAN INFORMATION

BASIC EXAMINATION

PRODUCT USAGE

ALLERGIES (SELECT ALL THAT APPLY)

Pet
Dye Allergies
Aspirin
Nitrate
Penicillin
Codeine
Seasonal
Food
Morphine
Sulfa Drug
None

OVER THE COUNTER MEDICATION

Pain Reliever
Antacid
Aspirin
Laxatives
Antidiarrheal
Diet Aids
Decongestant
Sleep Aids
Acetaminophen
Acid Blockers
Ibruprophen
Antihistamines
Cough Suppressant
Ketaprofen
Naproxen
None

PAST/PRESENT MEDICAL CONDITIONS

High Cholesterol
Thyroid
Heart Disease
Depression
Cancer
Arthritis
Ulcers
Blood Clotting Issue
Epilepsy
Diabetes
Eye Disease
Hormone Related
Migraines
High Blood Pressure
Lung Issues
Other

CURRENT MEDICATIONS, VITAMINS, AND SUPPLEMENTS

Are you currently taking any other medications, supplements, or vitamins?

FAMILY HISTORY (FATHER, MOTHER, SIBILINGS ONLY)

Heart Disease?
High Blood Pressure?
Diabetes?
Arthritis?
Skin Disorders?
Cancer?
BY SIGNING BELOW, I HEREBY DECLARE that, to the best of my knowledge and believef, the information given in these answers to Nu Image Medical is correctly recorded, complete and true and I agree that Nu Image Medical, believing them to be true, shall rely and act upon them accordingly.

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PLEASE SIGN ABOVE USING YOUR CURSOR TO ACKNOWLEDGE YOU'VE READ AND UNDERSTOOD ALL TERMS & CONDITIONS

WEIGHT-LOSS CONSUMER BILL OF RIGHTS 501.0575

“Off Label” Use of HCG
Statement from the FDA

PATIENT AUTHORIZATION AGREEMENT AND CONSENT

TERMS & CONDITIONS

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