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General Intake 2
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Other
TMJ (Jaw)
Morning Stiffness
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Ear Blockage
Ear Pressure
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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
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Dry/Cracked Skin
Itchy or Peeling Skin
Onychomycosis (Nail Fungus)
Energy
When is your energy highest?
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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
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Exercise
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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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Which best describes what you are experiencing
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