My Personal Medical Information - MyHealth Analysis™

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My Personal Medical Information

Your Personal Information: ( Required)

Getting Acquainted

Describe your occupation and the type of work you're involved in. If you are not employed, state so:


Does your work in any way interfere with your health? If yes, describe:	No Yes




Does your health in any way affect the quality or quantity of your work? If yes, describe:	No Yes




Have you ever been treated using clinical or therapeutic nutrition before? If yes, what treatment did you receive? Were you satisfied?	No Yes




Do you have any concerns, hesitations, or fears being treated with clinical or therapeutic nutrition? If yes, describe:	No Yes

This personal information will be saved into your MyHealth Record Profile. It will also be used by your on-line doctor to make personalized recommendations. Your history is also used to setup your free My Journal to make tracking your progress even easier.

Health and work problems are many times interrelated. Each can affect the other. Your on-line doctor will discuss this with you.

Please Tell Us Your Concerns
Being honest about your concerns will help your on-line doctor answer your questions. If you're not comfortable with this type of treatment, we want to know.

Please review this form to be sure you have answered the appropriate items and that your answers are accurate. Thank you for choosing BecomeHealthyNow.com. We look forward to helping you achieve your your health goals.

Please Note:

You have already completed this sub-section of the MyHealth Analysis questionnaire. Your answers are recorded above for you to review. If any of the data in the form is NOT correct and you need to CHANGE your answers, click the appropriate button below. You will then be allowed to make any necessary changes.

Please Note This Section is Complete:

You have already completed this entire section of the MyHealth Analysis questionnaire. Your answers are recorded above for you to review. If any of the data in this subsection or any other subsection is NOT correct and you need to CHANGE your answers, call your on-line doctor, {doc_name} at {doc_phone}. He will make this entire section incomplete and you will be able to make changes to any sub-section. Your previous answers will NOT be lost, and you will be able to review each sub-section and make changes.

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