91 Wood Ave, Suite 1, Ardsley, NY  10502  (866) 693-1115
http://www.doctorstevenpark.com
 
Dr. Park's Virtual Coaching Form

Personal Information

    
    
    

How did you find out about this virtual coaching program?
(please check all that applies)
 

Medical History

    
    
Are you allergic to any medications?  *
    
Are you allergic to any foods, animals, etc.? *
Are you currently taking any medications? *
Do you smoke? *
      
Do you drink alcohol? *
         
If yes, how much?
Did you ever undergo surgery? *
    
Do you have obstructive sleep apnea? * 
 



I understand that my coaching session is for educational and informational purposes only and will not be used as medical advice. I agree to talk to my doctor or other health care professional before making any changes to my medical, dietary, exercise or lifestyle regimen. I also understand that the fee is nonrefundable, once services are provided.
I agree with the above statement. * 

Powered byFormsiteReport abuse