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General Intake 2
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Treatment Goals
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Other
TMJ (Jaw)
Morning Stiffness
Difficulty Opening Jaw
Ear Blockage
Ear Pressure
Ear Ringing
Ear Stuffiness
Grinding
Clenching
Jaw Pain
Clicking
Locking
Difficulty Chewing
Feet
Onychoptosis (Nail Loss)
Pes Cavus (High Arch)
Pes Planus (Flat Feet)
Plantar Fasciitis
Bunions
Plantar Wart
Dry/Cracked Skin
Itchy or Peeling Skin
Onychomycosis (Nail Fungus)
Energy
When is your energy highest?
When is your energy lowest?
Do you struggle with insomnia?
Does your energy fluctuate?
How long do you sleep on average?
Is your energy constant?
What is your energy level upon awakening?
Well Being
Caffeine
Exercise
Flexibility
Range of Motion
Sports
Emotion / Memory
Anxiety Disorder
Mood Disorder
Stress
Female Health
Hysterectomy
PMS
Number of Pregnancies
Number of Live Births
Currently Pregnant
Area of Complaint
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Upper Back
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