Berri Healthy, LLC
Intake Form 2023
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Personal Info
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Contact Info
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Source of Referral
Address
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Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
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Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
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Cambodia
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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
Croatia
Cuba
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Dominica
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Heard Island And Mcdonald Islands
Holy See (Vatican City State)
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Isle Of Man
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Latvia
Lebanon
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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
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
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Pakistan
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Panama
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Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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
Other
Medical Info
Primary Complaint
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Massage Goals
Injury Rehabilitation
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Strength Training
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Stress Relief
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Flexibility
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Increase Well-Being
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Other
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Medium Pressure Preferred
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Deep Pressure Preferred
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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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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 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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Tailbone (coccyx)
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TMJ (Jaw)
Jaw Pain
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Locking
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Clenching
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Grinding
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Clicking
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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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Headaches
Migraines
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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Other Headaches
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Prenatal (check boxes to enter details below)
Name of midwife/OBGYN
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Other prenatal concerns
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Due Date
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Weeks Pregnant
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Number of previous pregnancies/births?
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Blood Clot (Phlebitis)
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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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Previous C-Section
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Carpal Tunnel Syndrome
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Allergy to Nut Oils
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High Risk Pregnancy
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Birth Location
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Doula
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Sacral Injury
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Tailbone Injury
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Cardiovascular
Heart Attack
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Blood Clots
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Coronary Artery Disease
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Phlebitis
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Lymphedema
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Aneurysm
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Hyperlipidemia
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Angina
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Pericarditis
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Raynaud Disease
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Cardiovascular Accident
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Atherosclerosis
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Pacemaker
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Cardiac Arrhythmia
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Heart Disease
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Blood Pressure
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High Blood Pressure
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Myocardial infarction
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Low Blood Pressure
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Varicose Veins
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Congestive Heart Failure
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Other Cardiovascular
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Musculoskeletal
Amyotrophic Lateral Sclerosis (ALS)
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Dupuytren's Contracture
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Tendonitis/Bursitis
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Degenerative Disk Disease
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Joint Injury
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Chronic Fatigue Syndrome
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Muscular Dystrophy
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Ehlers-Danlos Syndrome
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Osteoporosis
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Osgood-Schlatter Disease
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Osteoarthritis
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Myasthenia Gravis
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Joint Stiffness / Swelling
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Gout
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Ankylosing Spondylitis
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Osteomalacia
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Spondylolisthesis
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Spasms / Cramps
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Carpal Tunnel Syndrome
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Bone Disease
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Torticollis
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Artificial Joints / Special Equipment
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Compartment Syndrome
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Psoriatic Arthritis
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Recti Diastasis
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Dislocation
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Fibromyalgia
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Scleroderma
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Arthritis
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Jaw Pain (TMJD)
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Adhesive Capsulitis
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Fracture
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Plantar Fasciitis
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Scoliosis
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Strain/Sprain
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Whiplash
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Hereditary/Congenital Deformity
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Chronic Myofascial Pain Syndrome
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Other Musculoskeletal
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Neurological
Cerebral Vascular Accident (Stroke)
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Peripheral Neuropathy
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Cerebral-vascular Accident
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Loss of Sensation
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Seizure Disorder
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Post Polio Syndrome
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Stroke
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Transient Ischemic Attacks (TIA)
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Shingles / Herpes
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Vertebral and Spinal Cord Injury
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Huntington Disease
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Bell's Palsy
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Epilepsy
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Shingles
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Cerebral Palsy
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Numbness
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Brain Disorder
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Carpal Tunnel
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Dizziness
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Parkinsons
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Burning
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Chronic Pain Disorder
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Chiari Malformation
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Sciatic Pain
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Herniated Disc
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Tingling
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Brain Injury
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Fibromyalgia
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Multiple Sclerosis
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Other Neurological
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Respiratory
Respiratory Conditions
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Shortness of Breath
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Asthma
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Emphysema
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Sinus Problem
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Bronchitis
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COPD
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Cystic Fibrosis
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Other Respiratory
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Skin
Rash
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Hair Transplant
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Bruise Easily
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Rosacea
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Hypersensitive Reaction
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Athletes Foot
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Herpes
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Hypersensitive Reactions
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Melanoma
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Melanoma/Carcinoma
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Plantar's Wart
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Skin Conditions
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Infectious Skin Conditions
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Botox/Fillers
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Eczema
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Psoriasis
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Skin Irritations
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Athlete's Foot
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Acne
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Other Skin
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Blood
Polycythemia
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Haemophilia
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Hepatitis
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Blood Thinner Medication
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High Cholesterol
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HIV
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Fainting Spells
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Thrombosis/Embolism
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Stroke
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Anemia
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Bleeding Disorder
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HIV/AIDS
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Hypercoagulability
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Other Blood
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Reproductive
Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Pregnancy
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Gynaecological Conditions
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Uterine Disorder
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Ectopic Pregnancy
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Endometriosis
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Menopause
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Endocrine
Diabetes
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Hyperthyroidism
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Prostate Condition
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Hypothyroidism
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Adrenal Fatigue
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Other Endocrine
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Immune
Rheumatoid Arthritis
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Anaphylaxis
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Allergies
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Lupus
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Hodgkin Lymphoma
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Cancer
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HIV/Aids
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Leukemia
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Non-Hodgkin Lymphoma
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Other Immune
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Miscellaneous
Visually Impaired
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Contact Lens
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Surgical Pins or Wire
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Dentures
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Hearing Impaired
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Other Medical Conditions
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Other Diagnosed Diseases
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Allergy
Coconut Oil
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Latex
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