TR Community Healing Space Intake
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Personal Info
First Name
Last Name
Date of Birth
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Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
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Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
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Equatorial Guinea
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Faroe Islands
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Gabon
Gambia
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Greece
Greenland
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Guam
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
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Hungary
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Indonesia
Iran, Islamic Republic of
Iraq
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Republic of
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Kuwait
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
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Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
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Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
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Netherlands
Netherlands Antilles
New Caledonia
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Nigeria
Niue
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Northern Mariana Islands
Norway
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Panama
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Paraguay
Peru
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Poland
Portugal
Puerto Rico
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Réunion
Romania
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Rwanda
Saint Barthélemy
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
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
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
Insurance
Do you have extended health benefits?
yes
no
Insurance provider
Group Source
Provider Connect
Sunlife
Pacific Blue Cross
Greenfield
Claims Xchange (cooperators)
FNHA (PBC)
Other
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Policy #
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Member/Certificate ID
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Name of policyholder (if different than client)
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Relationship to policy holder
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Birth date of policy holder
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Medications
Medication
Add Another Medication
Conditions
Please list diagnosis and/or chronic health conditions
General Questions
What modalities have you tried before?
Acupuncture
Massage Therapy
Cranio Sacral Therapy
Osteopathy
Somatic Experiencing
Please list any current medications (prescription and over the counter), vitamins, supplements, herbs or homeopathic remedies that you are taking, including dosage if you know it
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Are you currently pregnant?
Yes
No
If Yes, what is the due date?
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Do you have a contagious disease at this time?
Yes
No
Do you have any of the following?
Pacemaker
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Epilepsy
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Surgical implants
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Blood thinners or Hemophilia
Fear of needles
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Hepatitis
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HIV
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Tuberculosis
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Latex allergy
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Nut allergy
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Other Allergy:
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Pain Questions
Nature of the Pain
Constant
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Comes and goes
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Dull
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Burning
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Aching
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Spasm
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Numb
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Does the pain get better, or worse with Heat?
Better
Worse
Does the pain get better, or worse with Cold?
Better
Worse
Does the pain get better, or worse with Motion?
Better
Worse
Does the pain get better, or worse with Rest?
Better
Worse
Does the pain get better, or worse with Pressure?
Better
Worse
Better in AM or PM?
AM
PM
Rate your Pain:
0 No pain.
1 Barely noticeable. Does not interfere with activities.
2 Mild pain. Aware of it, but easily ignored.
3 Mild but persistent. Noticeable and occasionally distracting.
4 Moderate pain. Interferes with some activities but still manageable.
5 Moderate pain. Difficult to ignore; affects concentration and daily tasks.
6 Moderately severe. Limits activities and may require rest or medication.
7 Severe pain. Difficult to function normally; most activities are limited.
8 Very severe pain. Unable to do many daily activities; pain is constantly present.
9 Extremely severe pain. Nearly unbearable; unable to focus on anything else.
10 Worst pain imaginable. Unbearable and incapacitating; immediate medical attention may be needed.
General Health Questionnaire
Check below what you consume per day and indicate how much:
Water
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Coffee
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Tea
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Soda
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Alcohol
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Cigarettes
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What are your typical eating habits?
Skip Meal(s)
Not hunger in AM
Excess Hunger
Cannot eat when Worried/Stressed
Eat When Not Hungry
No Desire to Eat
Craving specific food(s)
What are your typical sleeping habits?
Hours slept/night
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Trouble falling asleep
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Trouble staying asleep
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Frequent Dreams
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Disturbing dreams
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Wake at same time every night
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Other
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How would you describe your energy levels?
High
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Normal
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Low
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Lethargic
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Hyperactive Changes from day to day
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What is your Average Body Temperature?
Hot
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Cold
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Cold Hands & Feet
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Hotter at night
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Colder at night
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Hot Flashes
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Hot Joints
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Musculoskeletal:
Osteoarthritis
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Rheumatoid arthritis
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Body heaviness
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Broken Bones:
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Joint Pain
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Limit Motion
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Muscle Pain / Cramps
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Scoliosis
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Weight Gain
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Weight Loss
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Head, Eyes, Ears, Nose and Throat
Allergies / Hay Fever
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Concussion
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Dry mouth / nose
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Ear aches
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Excess phlegm in throat
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TMJ Syndrome / Jaw Pain
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Headaches / Migraines
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Red, dry and/or itchy eyes
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Spots in eyes
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Sinus issues
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Ringing in ears
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Other
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Respiratory & Cardiovascular
Asthma
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Frequent colds
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Chronic cough
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Emphysema or COPD
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Heavy or tight chest feeling
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Anemia
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Easily bruised
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Poor Circulation
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Blood Clots
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Fainting
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High Cholesterol
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High Blood Pressure
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Low Blood Pressure
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Heart Palpitations
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Chest Pains
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Irregular Heart Beat
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Pace Maker
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Phlebitis
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Stroke
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Heart Disease
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Other
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Gastrointestinal
Normal Stool
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Loose stool
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Constipation
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Diarrhea
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Undigested food in Stool
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Heart Burn / Acid Reflux
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Abdominal Pain
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Bloating / Gas
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Nausea / Vomiting
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Hernia
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Liver Disorder
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Other
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Urinary
Frequent Bladder infections
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Incontinence
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Kidney stones
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Frequent urination
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Prostate Disorder
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Kidney Disease
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Other
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Gynecological (Females Only)
Menopause
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Breast lumps
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Genital burning, itching, discharge or swelling
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Hysterectomy
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Endometriosis
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Fibroids or cysts
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PMS
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Heavy Periods
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Light periods
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Irregular Periods
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Other
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Number days between periods:
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Number days of period:
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Number of pregnancies:
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Number of miscarriages:
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Skin and Hair
Acne
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Dermatitis
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Eczema
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Fungal infection
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Heavy sweating
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Not able to sweat
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Hives
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Itchy, Dry Skin
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Psoriasis
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Rashes
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Shingles
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Other
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Neurological & Psychological
ADD / ADHD
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Addition
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Anxiety
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Depression
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Easily Stressed
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Epilepsy / Seizure Disorder
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Irritability
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Foggy head feeling
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Poor Circulation
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Parkinsons
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Poor Memory
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Vertigo / Dizziness
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Other
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Any other health concerns you would like to share?
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