Have you done any blood work in the last 2 years? If so, please provide results. ________________________________________________________________ Have you ever had any reconstructive surgery to the breasts? Any implants? What kind and when? Have you ever had a Breast Thermogram? If so, when? Please include copies of your reports. Please provide your age _______ Date of Birth _________________ (This is for requisitions for any lab work, should you decide to order some tests) Height _____________ Weight _____________ If you can also send a photograph of your beautiful self, I would appreciate it. I like to see the face and not just hear the voice. Even if we Skype, I like to keep a photograph of you in your file. Thank you. Waiver and Disclaimer: I understand that the 7 Essentials Coaching Program is for informational purposes only and not medical advice. It is not meant or designed to make any medical claim about treating or curing cancer or any type of disease. The 7 Essentials Coaching Program is not intended as a substitute for the diagnosis, treatment or advice of a qualified, licensed medical professional. The 7 Essentials Coaching Program is not medical advice, nor does it replace the recommendations from your primary care physician. It is highly encouraged that you do not disregard the medical advice that you have been concerning treatments and medications from your primary care physician.
Have you done any blood work in the last 2 years? If so, please provide results. ________________________________________________________________ Have you ever had any reconstructive surgery to the breasts? Any implants? What kind and when? Have you ever had a Breast Thermogram? If so, when? Please include copies of your reports. Please provide your age _______ Date of Birth _________________ (This is for requisitions for any lab work, should you decide to order some tests) Height _____________ Weight _____________ If you can also send a photograph of your beautiful self, I would appreciate it. I like to see the face and not just hear the voice. Even if we Skype, I like to keep a photograph of you in your file. Thank you. Waiver and Disclaimer: I understand that the 7 Essentials Coaching Program is for informational purposes only and not medical advice. It is not meant or designed to make any medical claim about treating or curing cancer or any type of disease. The 7 Essentials Coaching Program is not intended as a substitute for the diagnosis, treatment or advice of a qualified, licensed medical professional. The 7 Essentials Coaching Program is not medical advice, nor does it replace the recommendations from your primary care physician. It is highly encouraged that you do not disregard the medical advice that you have been concerning treatments and medications from your primary care physician.
Questionnaire-6-14-R.docx