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Medical Info
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General Health
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Medications
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Additional Info
Conditions
TMJ (Jaw)
Difficulty Opening Jaw
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Grinding
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Jaw Pain
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Clicking
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Locking
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Difficulty Chewing
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Ear Blockage
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Treatment: Surgery
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Treatment: Chemotherapy
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Treatment: Radiation
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Nausea
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Pressure Sensitivity
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Pain
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Loss of Movement
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Systemic Infection
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Infectious Condition
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Enlarged Liver
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Area of Complaint
Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Right Shoulder
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Left Elbow
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Left Hand
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Brain Disorders
Claustrophobia
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Acute Stress Disorder
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Depression
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ADD
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Generalized Anxiety Disorder
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ADHD
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PTSD
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Autism
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Schizophrenia
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Asperger Syndrome
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Sleep Disorder
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Bipolar Disorder
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Borderline Personality Disorder
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Headaches
Cluster
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Migraines
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Rebound
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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Neurological
Parkinsons
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Epilepsy
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Herniated Disc
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Vertebral and Spinal Cord Injury
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Multiple Sclerosis
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Shingles
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Brain Disorder
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Dizziness
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Chronic Pain Disorder
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Numbness
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Brain Injury
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Stroke
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Sciatic Pain
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Seizure Disorder
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Loss of Sensation
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Cerebral Palsy
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Other Neurological
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Respiratory
Bronchitis
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Asthma
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Infectious Respiratory Conditions
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Other Respiratory
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Skin
Athletes Foot
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Skin Irritations
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Plantar's Wart
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Psoriasis
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Rash
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Infectious Skin Conditions
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UV Burn
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Bruise Easily
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Eczema
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Acne
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Sensitive Skin
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Other Skin
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Immune
Infectious Mononucleosis
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Non-Hodgkin Lymphoma
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Lupus
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Rheumatoid Arthritis
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Allergies
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Hodgkin Lymphoma
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Other Immune
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Musculoskeletal
Fibromyalgia
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Amyotrophic Lateral Sclerosis (ALS)
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Arthritis
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Whiplash
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Muscular Dystrophy
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Osteoporosis
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Dislocation
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Artificial Joints / Special Equipment
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Fracture
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Joint Injury
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Tendonitis/Bursitis
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Scoliosis
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Carpal Tunnel Syndrome
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Degenerative Disk Disease
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Plantar Fasciitis
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Sinus Problems
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Strain/Sprain
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Other Musculoskeletal
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Cardiovascular
High Blood Pressure
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Low Blood Pressure
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Aneurysm
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Congestive Heart Failure
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Heart Attack
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Blood Clots
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Cardiovascular Conditions
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Varicose Veins
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Lymphedema
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Pacemaker
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Heart Disease
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Other Cardiovascular
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Hearing
Motion Sickness
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Vertigo
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Other Hearing
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Blood
Thrombosis/Embolism
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Bleeding Disorder
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Other Blood
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Miscellaneous
Insomnia
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Surgical Pins or Wire
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Anemia
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Leaking Amniotic Fluid
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Nausea
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Pre-eclampsia (toxemia)
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Sciatica
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Sacral Injury
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Tailbone Injury
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Massage Goals
Increase Well-Being
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Injury Rehabilitation
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Stress Relief
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Address Health Issues
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Alternative Therapy
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Flexibility
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Improve Fitness
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Other
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Emotion / Mood
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