{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fnil\fcharset0 Courier New;}{\f1\fnil\fcharset0 Times New Roman;}{\f2\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.21.2509;}\viewkind4\uc1\pard\nowidctlpar\sl240\slmult1\kerning28\f0\fs20 ION-CLEANSE HEALTH QUESTIONNAIRE:\par \par \par Today\rquote s Date: ____________\tab\par \par Name: ________________________________________________________________\par \par Address: ______________________________________________________________\par \par Phone Number: _________________________________________________________\par \i\par Answers to health questions are for our records only and are confidential.\par \i0\par 1. Are you now under a doctor\rquote s care? Yes ___ No ___ \par \par If yes, for what reason?________________________________________\par \par 2. Are you taking any drugs or medications at this time? Yes___ No ___\par \par If yes, please list them and reason for taking them? Also, what time(\lquote s) of day do you take your medication? \par \par _______________________________________________________________________ \par _______________________________________________________________________\par \par 3. Are you an organ transplant recipient? Yes ___ No ___\par \par If so, are you on medication to prevent rejection of a transplanted organ? Yes ___ No___\par \par 4. Are you pregnant or breastfeeding at this time? Yes ___ No ___\par \par 5. Do you wear a pacemaker or any other battery operated or electrical implant? Yes ____ No_____ \par \par 6. Are you on mental health medications? Yes ___ No ___\par If so, do you have symptoms if you miss one or more doses? Yes___ No___\par \par 7. Are you on blood-thinning medication? Yes ___ No ___\par \par 8. Are you currently taking a course of chemotherapy treatment? \par Yes ___ No ___\par \par 9. Do you have any health problems that we should know about? \par \par _______________________________________________________________________\par \par \par ***********************************************************************\par The IonCleanse is intended to support herbal, homeopathic, and vitamin detoxification protocols and procedures. We make no claims of treatment of diseases and illness. No medical claims are made or implied.\par \par Please Note: Any missed appointment without 48-hour notice will be charged $30.00. The charge will be taken off of any package visits you may have on account or may be deducted from your credit card. All package programs are non-refundable. I certify that everything on this form is true and correct to the best of my knowledge.\par \par Client Signature: _______________________________________________\par \f1\par \pard\kerning0\f2\par }