Patient Intake form & Policies (2024-2025)
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Contact Info
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Australia
Canada
Ireland
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United States
Afghanistan
Albania
Algeria
American Samoa
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Bouvet Island
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Chad
Chile
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Costa Rica
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Falkland Islands (Malvinas)
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Heard Island And Mcdonald Islands
Holy See (Vatican City State)
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Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
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Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
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Macao
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
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Mayotte
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Panama
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Romania
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Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
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Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
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Swaziland
Sweden
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Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
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Tokelau
Tonga
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Tunisia
Turkey
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Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Conditions
Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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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 Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Headaches
Migraines
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Cluster
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Sinus
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Tension
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Neurological
Brain Injury
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Sciatic Pain
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Seizure Disorder
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Stroke
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Transient Ischemic Attacks (TIA)
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Epilepsy
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Parkinsons
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Chronic Pain Disorder
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Cardiovascular
Congenital Heart Defect
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Varicose Veins
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Heart Attack
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Aneurysm
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Lymphedema
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Pacemaker
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Raynaud Disease
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High Blood Pressure
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Low Blood Pressure
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Reproductive
Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Pregnancy
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Breast Disorder
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Menopause
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Immune
Allergies
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Lupus
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Cancer
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Leukemia
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Musculoskeletal
Strain/Sprain
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Amyotrophic Lateral Sclerosis (ALS)
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Osteoporosis
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Muscular Dystrophy
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Ankylosing Spondylitis
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Gout
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Tendonitis/Bursitis
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Bone Disease
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Fibromyalgia
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Arthritis
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Jaw Pain (TMJD)
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Scoliosis
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Gastrointestinal
Stomach Disorder
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Crohn's Disease
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Blood
Hepatitis
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Thrombosis/Embolism
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Anemia
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HIV/AIDS
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Skin
Athlete's Foot
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Psoriasis
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Herpes
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Melanoma/Carcinoma
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Skin Conditions
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Respiratory
Asthma
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Bronchitis
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COPD
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Hearing
Tinnitus
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Vertigo
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Endocrine
Diabetes
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Hyperthyroidism
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Hypothyroidism
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Prostate Condition
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Miscellaneous
Vision Problems
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Mental Health Issues
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Surgical Pins or Wire
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Insomnia
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Other Medical Conditions
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Other Diagnosed Diseases
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Medications
Medication
Add Another Medication
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
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Policies (2024-2025)
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