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Emergency Contact
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Doctor
Doctor's Name
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Medications
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Additional Info
Conditions
Emotion / Memory
Anxiety Disorder
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Mood Disorder
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Stress
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Side Effects of Chemo
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Treatment: Radiation
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Area of Radiation
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Side Effects of Radiation
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Other Treatments
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Nausea
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Weight Loss
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Weight Gain
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Bone Pain
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Blood Clot
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Excessively Warm/Cold
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Dry Skin
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Radiation Skin Reaction
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Fatigue
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Current Tumour
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Enlarged Lymph Nodes
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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
Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Respiratory
Chronic Cough
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Shortness of Breath
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Asthma
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Respiratory Conditions
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Neurological
Huntington Disease
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Shingles
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Numbness
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Dizziness
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Parkinsons
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Sciatic Pain
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Chronic Pain Disorder
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Stroke
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Epilepsy
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Herniated Disc
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Brain Injury
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Tingling
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Multiple Sclerosis
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Cerebral Vascular Accident (Stroke)
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Seizure Disorder
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Loss of Sensation
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Cardiovascular
Cold Feet
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Blood Pressure
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Phlebitis
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Pacemaker
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Blood Clots
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Varicose Veins
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High Blood Pressure
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Cardiovascular Conditions
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Heart Disease
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Lymphedema
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Low Blood Pressure
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Cold Hands
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Kidney
Kidney Stones
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Chronic Kidney Disease
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Immune
Allergies
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Rheumatoid Arthritis
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Lupus
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Endocrine
Diabetes
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Hyperthyroidism
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Hypothyroidism
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Musculoskeletal
Compartment Syndrome
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Psoriatic Arthritis
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Sinus Problems
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Fibromyalgia
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Plantar Fasciitis
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Artificial Joints / Special Equipment
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Scleroderma
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Jaw Pain (TMJD)
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Scoliosis
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Tendonitis/Bursitis
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Chronic Fatigue Syndrome
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Strain/Sprain
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Arthritis
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Spondylolisthesis
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Joint Injury
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Amyotrophic Lateral Sclerosis (ALS)
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Osteoarthritis
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Ehlers-Danlos Syndrome
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Osgood-Schlatter Disease
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Carpal Tunnel Syndrome
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Ankylosing Spondylitis
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Bone Disease
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Osteoporosis
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Skin
Plantar's Wart
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Psoriasis
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Allergic Dermatosis
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Athlete's Foot
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Rash
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Rosacea
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Bruise Easily
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Skin Conditions
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Skin Irritations
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Melanoma
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Gastrointestinal
Celiac Disease
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Irritable Bowel Syndrome
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Crohn's Disease
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Digestive Conditions
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Esophageal Disorder
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Hearing
Motion Sickness
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Hearing Loss
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Tinnitus
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Vertigo
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Miscellaneous
Vision Problems
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Surgical Pins or Wire
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Mental Health Issues
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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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Blood Clot (Phlebitis)
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Edema/Swelling
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Leg Cramps
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Nausea
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Pre-eclampsia (toxemia)
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Sciatica
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Previous C-Section
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High Risk Pregnancy
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Massage Goals
Stress Relief
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Alternative Therapy
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Positive Reinforcement
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Increase Well-Being
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