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Title
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Name:*
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Date of birth
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Phone:*
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Email:*
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Weight
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Approx. hours worked per week.
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Description of duties
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Fitness Levels
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Exercise per week
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Description of excercise
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Reason for online consultation
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Areas of concern.
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Description of the problem
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What aggravates the problem?
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What (if anything) eases the issue?
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Time of day when at its worst
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Previous treatment received for this issue
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How long ago?
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Previous ailments and treatments
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Are You A New Patient?*
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