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MEDICAL HISTORY AND SCREENING FORM

All information will be kept confidential. This information will be used for the evaluation of your health and readiness to begin the Resolution program. Please try to answer the following questions as accurately and completely as possible. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out. Your answers will help us design a comprehensive program that meets your individual needs.

Name: Katherine Seyton

Address: 26 Albany Park Ave.

Birth date: 20/08/1982

May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?

Yes/No

Do you suffer from migraines?

Yes/No

Do you have a history of high blood pressure?

Yes/No 

Do you smoke and if so how many a day?

Yes/No

Do you suffer from insomnia?

Yes/No

 If so how frequently?

Occasionally

Regularly

All the time

Resolution is an experimental treatment and as such may have unexpected side-effects; if you experience any unusual symptoms during or, after your treatment, consult with the leading technician immediately.

Signature: Katherine Seyton

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