Name

First Name

Last Name

Please Check All Injuries or Medical Conditions That You Have Had or Currently Have:

Respiratory - Lungs (Asthma, COPD, SOB, Cancer, Cystic Fibrosis)

Cardiovascular - Heart (Heart Attack, Stroke, Hypertension, CHF, AFIB, DVT, Edema)

Endocrine - Glandular (Diabetes, Thyroid, Testosterone, Adrenal, Pancreatic)

Gastrointestinal - Digestive (GERD, IBS, Crohn's, Colitis, Ulcer, Gastritis, Hernia, Hepatitis, Liver, Gallbladder)

Ears - Nose - Throat - Mouth (Hearing, Tinnitus, Allergies, Sinusitis, Breathing, TMJ, Dental)

Arthritis (Osteoarthritis, Rheumatoid, Lupus, Gout)

Blood (Anemia, Spleen Disease, Leukemia)

Urinary (Prostate, Kidney, Bladder)

Sexual Dysfunction

Vision (Glaucoma, Cataracts, Macular Degeneration)

Skin (Pruritus, Scars, Grafts, Allergies, Burns, Dermatitis, Eczema, Cancer)

Headaches

Psychological (Depression, Anxiety, Stress, PTSD, Sleep, Memory, Concentration, Dyslexia, Phobias, Suicidal Thoughts)

General (Surgeries, Hospitalizations, STDs, Epilepsy, Cancer, Bone, Joint, Muscle, Fractures, Amputations, Paralysis, Hysterectomy)