Virtual Consult Questionnaire

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Virtual Consult Questionnaire

S.I.C. Virtual Consult Questionnaire

OHO SEMINARS VIRTUAL CONSULTATION QUESTIONNAIRE

Please fill out the questionnaire below to get started. The questionnaire must be submitted no less than 24 hours prior to your consult.

Name

First

Last

Email address of consultee:

Time Zone

Type of Consult

Date of Birth

Gender

Occupation

Weight

Choose your measurement of weight:

Height

Primary Goal of Consult

Problem List (current or previous resolved diagnosises - from Eastern or Western Practioners):

Symptom History

Physician's Notes

How Did You Find Us?

Did you submit all of your daily questionnaires?

Yes

Complete Daily Vitals Form

Please complete the following form and enter information for each day if you have chosen "no". You will be unable to proceed until you have completed the Daily Virtual Follow Ups HERE

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ADMIN AREA

Diagnosis

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Herbacy Prescription

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