Date:

Name:

Age:

Address:

Phone:

Email:

Current Occupation:

Military Service / Deployment History:

Branch of Service:

Discharge Date:

Support Needed to do the Detoxification Program:
(housing, transportation, etc.)

Primary Health Complaint:

Other post deployment symptoms:

Military Exposure information
(chemicals, radiation, inoculations, medications, environmental exposures, etc.):

Treatments recommended to date:

What were the results?

Full medical history on file?
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