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Medical Information
Date of Surgery/Injury:
Have Xrays or MRI's been taken?
Yes
No
Results:
General Information
Age:
Occupation:
Relevant sports/hobbies:
Daily life physical limitations:
General Health
Diabetes?
Yes
No
Heart Trouble?
Yes
No
Epilepsy?
Yes
No
High blood Pressure?
Yes
No
Circulation Problems?
Yes
No
Osteoporosis?
Yes
No
Bowel/Bladder Problems?
Yes
No
Do you smoke?
Yes
No
Have you ever had cancer?
Yes
No
Have you ever experienced dizziness or blackouts?
Yes
No
Sudden weight loss?
Yes
No
Breathing Problems?
Yes
No
Are You Pregnant?
Yes
No
Recent Surgery?
Yes
No
Arthritis?
Yes
No
Describe any other health problems:
List any allergies:
List any medications you are taking:
What do you hope to gain from your treatment?
Emergency Contact:
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