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Province / State
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Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
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Medical Info
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General Health
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Medications
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Additional Info
Insurance Info
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Email Address
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Claims / Benefit
Conditions
Energy
Does your energy fluctuate?
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Is your energy constant?
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What is your energy level upon awakening?
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How long do you sleep on average?
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When is your energy highest?
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Do you struggle with insomnia?
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When is your energy lowest?
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Energy Level
Even
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Female Health
Menstrual Cramping
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Breast Cancer
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Currently Pregnant
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Pelvic Floor Injury
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Shoulder
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Right Shoulder
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Gluteal
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Right Gluteal
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Left Foot
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Right Foot
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Headaches
Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Cluster
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Rebound
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Sinus
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Other Headaches
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Brain Disorders
PTSD
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Bipolar Disorder
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Depression
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Generalized Anxiety Disorder
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Musculoskeletal
Artificial Joints / Special Equipment
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Plantar Fasciitis
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Strain/Sprain
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Sinus Problems
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Ehlers-Danlos Syndrome
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Myasthenia Gravis
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Fibromyalgia
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Ankylosing Spondylitis
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Jaw Pain (TMJD)
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Dislocation
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Whiplash
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Fracture
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Joint Injury
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Osteomalacia
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Tendonitis/Bursitis
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Scoliosis
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Osteoporosis
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Neurological
Numbness
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Tingling
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Brain Injury
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Cardiovascular
High Blood Pressure
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Blood Clots
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Lymphedema
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Cold Hands
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Skin
Skin Conditions
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Blood
Bleeding Disorder
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Hypercoagulability
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Thrombosis/Embolism
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Haemophilia
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Reproductive
Endometriosis
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Menopause
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Pregnancy
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Menstrual Cycle Disorder
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Pelvic Inflammatory Disease
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Other Reproductive
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Gastrointestinal
Digestive Conditions
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Immune
Allergies
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Miscellaneous
Other Medical Conditions
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Prenatal (check boxes to enter details below)
Weeks Pregnant
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Allergy to Nut Oils
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Emotion / Mood
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