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Neck Pain
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Back Pain/Problems
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Elbow/Wrist Pain
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Shoulder Problems
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Knee Injuries
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Hip Disorders
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TMJ Issues
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Foot/Ankle Pain
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Osteoporosis
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Poor Posture
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Scoliosis
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Arthritis
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Anxiety
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Depression
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Headache
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Dizziness
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Pins and Needles
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Numbness
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High Blood Pressure
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Low Blood Pressure
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High Cholesterol
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Poor Circulation
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Angina
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Excessive Bruising
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Asthma
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Apnea
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Emphysema
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Hay Fever
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Shortness of Breath
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Pneumonia
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Anorexia/Bulimia
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Ulcers
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Food Sensitivities
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Heartburn
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Constipation
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Diarrhea
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Blurred Vision
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Ringing in Ears
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Hearing Loss
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Chronic Ear Infection
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Loss of Smell
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Loss of Taste
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Skin Cancer
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Psoriasis
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Eczema
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Acne
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Hair Loss
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Rash
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Thyroid Issues
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Immune Disorders
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Hypoglycemia
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Frequent Infection
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Swollen Glands
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Low Energy
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Kidney Stones
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Infertility
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Bedwetting
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Prostate Issues
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Erectile Dysfunction
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PMS Symptoms
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Fainting
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Low Libido
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Poor Appetite
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Fatigue
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Sudden Weight Change
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Weakness
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AIDS
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Alcoholism
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Allergies
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Arteriosclerosis
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Cancer
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Chicken Pox
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Diabetes
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Epilepsy
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Glaucoma
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Goiter
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Gout
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Heart Disease
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Hepatitis
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Malaria
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Measles
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Multiple Sclerosis
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Mumps
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Polio
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Rheumatic Fever
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Scarlet Fever
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Sexually Transmitted Disease
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Stroke
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Tuberculosis
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Typhoid Fever
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Ulcer
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Other
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Had fractured/broken bones?
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Had spine/nerve disorder?
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Been knocked unconscious?
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Been injured in an accident?
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Have you ever used crutches?
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Used a back/neck brace?
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Tattoos
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Body Piercings
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Previous or Current Treatments
• • •
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Alcohol Use
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Coffee Use
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Tobacco Use
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Exercise
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Pain Relievers
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Soft Drinks
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Water Intake
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Smoker
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Job Pressure/Stress
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Vaccinated
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