Preserving Wellness
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Health History Questionnaire

Click the link below to open and print this .PLEASE remember to bring this completely filled out at your first visit. Or scan and email to me it is VERY important.

  • Health History Questionnaire (PDF format)
  • Male Intake Questionnaire (PDF format)
  • Female Intake Questionnaire (PDF format)
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© 2019 Optimal Health and Regenerative Medicine     |     2340 S. Highland Ave, Suite 370     |     Lombard, IL 60148     |     Phone: (630) 561-5531