Name
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Phone
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Email
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Address
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City, State, Zip
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Have you taken antibiotics in the last six months?
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Have you taken antibiotics long term such as for acne at any time?
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Female: Have you been pregnant more than once?
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Have you ever taken steroid medications?
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Are your symptoms made worse on damp, moldy days?
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Do you suffer from poor memory, lethargy, or feeling 'drained'?
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Do you suffer from constipation, diarrhea, or alternating between both?
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Do you suffer from a feeling of "spacey" or fuzzy thinking?
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Female: Have you ever had a localized vaginal yeast problem?
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Male: Have you ever had Prostatitis or suffer from impotence?
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