Charlotte Westbrook's Clinic
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General Health
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Male Health
Urinary Stream Changes
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Painful Urination
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Difficulty Maintaining Erection
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Nocturnal Urination
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Difficulty Obtaining Erection
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Family History of Prostate Disease
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History of Back Injury
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Sperm Count Results
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Energy
How long do you sleep on average?
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Do you struggle with insomnia?
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Female Health
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Implants
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Fibroids
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PCOS
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Uterine Polyps
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Brown Spotting
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Pencil Like Stool
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Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low 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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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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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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Sacrum
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Headaches
Tension
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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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Cardiovascular
Cold Hands
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Cold Feet
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Cardiac Arrhythmia
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High Blood Pressure
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Low Blood Pressure
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Blood Clots
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Varicose Veins
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Lymphedema
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Respiratory
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COPD
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Asthma
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Cystic Fibrosis
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Emphysema
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Bronchitis
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Kidney
Chronic Kidney Disease
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Congenital Kidney Disease
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Kidney Stones
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Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Other Kidney
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Family History
Cancer
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Arthritis
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Cardiovascular
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Diabetes
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Respiratory
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Reproductive
Ectopic Pregnancy
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Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pregnancy
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Pelvic Inflammatory Disease
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Gynaecological Conditions
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Premenstrual Syndrome
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Breast Disorder
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Uterine Disorder
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Other Reproductive
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Gastrointestinal
Irritable Bowel Syndrome
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Digestive Conditions
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Constipation
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Poor Appetite
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Diarrhea
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Stomach Disorder
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Diverticulitis
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Eating Disorder
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Ulcerative Colitis
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Esophageal Disorder
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Gastroparesis
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Fecal Impaction
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Crohn's Disease
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Intestinal Polyps
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Celiac Disease
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Other Gastrointestinal
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Immune
Anaphylaxis
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Leukemia
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Lupus
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Non-Hodgkin Lymphoma
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Allergies
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Cancer
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Hodgkin Lymphoma
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Rheumatoid Arthritis
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Infectious Mononucleosis
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Musculoskeletal
Compartment Syndrome
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Gout
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Dupuytren's Contracture
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Psoriatic Arthritis
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Sinus Problems
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Tendonitis/Bursitis
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Whiplash
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Dislocation
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Chronic Myofascial Pain Syndrome
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Scleroderma
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Fracture
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Chronic Fatigue Syndrome
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Osteoporosis
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Scoliosis
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Fibromyalgia
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Hereditary/Congenital Deformity
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Spondylolisthesis
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Strain/Sprain
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Carpal Tunnel Syndrome
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Joint Injury
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Jaw Pain (TMJD)
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Ehlers-Danlos Syndrome
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Artificial Joints / Special Equipment
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Amyotrophic Lateral Sclerosis (ALS)
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Temporomandibular Joint Dysfunction
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Osgood-Schlatter Disease
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Muscular Dystrophy
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Torticollis
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Ankylosing Spondylitis
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Osteomalacia
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Myasthenia Gravis
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Osteoarthritis
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Baker's Cyst
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Recti Diastasis
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Degenerative Disk Disease
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Bone Disease
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Plantar Fasciitis
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Arthritis
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Paget Disease
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Other Musculoskeletal
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Skin
Skin Conditions
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Psoriasis
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Skin Irritations
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Rash
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Eczema
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Acne
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Herpes
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Athletes Foot
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Athlete's Foot
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Hypersensitive Reactions
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Surgical Scars
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Bruise Easily
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Melanoma/Carcinoma
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Infectious Skin Conditions
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Plantar's Wart
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Blood
Thrombosis/Embolism
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Anemia
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Haemophilia
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Hepatitis
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High Cholesterol
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Bleeding Disorder
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HIV
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HIV/AIDS
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Hypercoagulability
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Polycythemia
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Neurological
Huntington Disease
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Cerebral Palsy
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Brain Disorder
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Numbness
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Loss of Sensation
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Shingles
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Parkinsons
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Chronic Pain Disorder
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Brain Injury
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Burning
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Dizziness
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Herniated Disc
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Cerebral Vascular Accident (Stroke)
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Tingling
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Multiple Sclerosis
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Seizure Disorder
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Stabbing
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Epilepsy
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Transient Ischemic Attacks (TIA)
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Sciatic Pain
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Stroke
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Cerebral-vascular Accident
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Vertebral and Spinal Cord Injury
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Hearing
Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Tinnitus
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Ear Problems
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Vertigo
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Hearing Loss
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Endocrine
Prostate Condition
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Diabetes
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Acute Pancreatitis
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Hyperthyroidism
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Hypothyroidism
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Pituitary and Growth Disorder
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Other Endocrine
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Miscellaneous
Insomnia
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Vision Problems
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Surgical Pins or Wire
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Other Medical Conditions
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Eating Habits
Breakfast
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Lunch
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Dinner
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Snacks
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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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Number of previous pregnancies/births?
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Anemia
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Leaking Amniotic Fluid
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Bladder Infection
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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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Leg Cramps
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Miscarriage
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Nausea
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Problems with Placenta
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Preterm Labour
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Pre-eclampsia (toxemia)
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Sciatica
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Separation of Rectus Muscle (diastasis recti)
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Separation of Symphysis Pubis
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Twins or More
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Visual Disturbances
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Previous C-Section
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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Hypoglycemia
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High Risk Pregnancy
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Birth Location
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Doula
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Placental Location
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Baby's Sex
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Sacral Injury
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Tailbone Injury
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Massage Goals
Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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Massage Frequency
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Other
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Accident Info
Date of Injury
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Emotion / Mood
Negative Self-Talk
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Anger
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0
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Other Emotions
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Anxiety
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Fear
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PTSD
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Sadness
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Stress Response and Coping Strategies
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Depression
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0
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Overall mood and energy level
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0
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Grief
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Rate the stress in your life (1-10)
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Despair
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