Getting Acquainted
First Name
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Last Name
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Date of Consultation
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How can I help you?
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How motivated are you to achieve this goal (10=highly motivated)
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Select
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10
What other things have you done to try to solve this problem?
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Do any of the following apply to you: past heart attack, have a pacemaker, other heart condition, epilepsy, concussion not medically cleared from, being treated for a psychiatric issue?
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Yes
No
If you answered yes to the question above, please explain
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