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123-456-7890
Email
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First Name
Last Name
Email
Address
Postal Code
Birthday
Date
Phone
Emergency Conact Name and Phone Number
What is your primary reason for the Appointment
When did this health concern start? Is it improving, worsening or unchanging?
Are you seeing anyone else regarding this issue (Doctor, Chiropractor, Physiotherapist, etc.)?
Indicate which part of the body the problem is occuring
Currently Pregnant?
Check All that Apply
General
Poor Circulation
Loss of Weight
Blood Sugar Issues
Allergies
Vision Problems
Hearing Problems
Frequent Colds/Flus
Bruise Easily
HIV/STD
Bodily Systems
Urinary Issues
Kidney Stones
Thyroid Problems
Gas/Bloating
Constipation/Diarrhea
Eczema/Psoriasis
Varicose Veins
Asthama
Heart Disease
Blood Clotting Disorder
High Blood Pressure
Stroke
Cancer
Choice 5
Musculskeletal
Back Pain
Neck Pain
Shoulder Pain
Arm/Wrist Pain
Hip Pain
Leg/Knee Pain
Ankle/Foot Pain
Osteoporosis
Scoliosis
Arthritis
Jaw Pain
Hernia
Whiplash
Bursitis
Fracture
Nerve System
Vertigo
Dizziness
Fainting
Headaches
Tinnitus
Depression
Insomnia
Chronic Fatigue
Fibromyalgia
Epilepsy
Medications (Including Herbs)
Any other medical conditions, injuries, and/or surgeries.
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