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Dr James Kho – New Patient Questionnaire
Codesquad
2023-07-27T16:38:47+08:00
Questionnaire
Dr James Kho – New Patient Questionnaire
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*
" indicates required fields
Name
*
First
Email
*
Date of Birth
*
DD slash MM slash YYYY
Contact Number
*
What is your main reason for coming here? (Or why were you referred here?). Please be as specific as you can and as detailed as you can:
Past surgery – please list all surgery you have had (and the year it occurred)
Past Medical History – please list all illnesses you have now, or have had (and the year they began)
Medications and Nutrients – please list ALL script medications, vitamins, minerals, herbals, and homeopathics you use daily or sometimes.
Diet – Do you follow any specific diet protocols?
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