Charlotte Westbrook's Clinic
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TMJ (Jaw)
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Male Health
Urinary Stream Changes
Painful Urination
Difficulty Maintaining Erection
Nocturnal Urination
Difficulty Obtaining Erection
Family History of Prostate Disease
Painful Ejaculation
Family History of Prostate Cancer
History of Back Injury
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PSA Test Results
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Sperm Count Results
Energy
How long do you sleep on average?
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What is your energy level upon awakening?
Female Health
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Spondylolisthesis
Strain/Sprain
Carpal Tunnel Syndrome
Joint Injury
Jaw Pain (TMJD)
Ehlers-Danlos Syndrome
Artificial Joints / Special Equipment
Amyotrophic Lateral Sclerosis (ALS)
Temporomandibular Joint Dysfunction
Osgood-Schlatter Disease
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Burning
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Herniated Disc
Cerebral Vascular Accident (Stroke)
Tingling
Multiple Sclerosis
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Epilepsy
Transient Ischemic Attacks (TIA)
Sciatic Pain
Stroke
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Vertebral and Spinal Cord Injury
Hearing
Conductive Hearing Loss
Meniere Disease
Motion Sickness
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Ear Problems
Vertigo
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Endocrine
Prostate Condition
Diabetes
Acute Pancreatitis
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Pituitary and Growth Disorder
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Miscellaneous
Insomnia
Vision Problems
Surgical Pins or Wire
Other Medical Conditions
Eating Habits
Breakfast
Lunch
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Prenatal (check boxes to enter details below)
Due Date
Trimester
Weeks Pregnant
Number of previous pregnancies/births?
Anemia
Leaking Amniotic Fluid
Bladder Infection
Blood Clot (Phlebitis)
Abdominal Cramping
Diabetes
Edema/Swelling
Leg Cramps
Miscarriage
Nausea
Problems with Placenta
Preterm Labour
Pre-eclampsia (toxemia)
Sciatica
Separation of Rectus Muscle (diastasis recti)
Separation of Symphysis Pubis
Twins or More
Visual Disturbances
Previous C-Section
Heart Attack
Stroke
Carpal Tunnel Syndrome
Allergy to Nut Oils
Hypoglycemia
High Risk Pregnancy
Birth Location
Doula
Placental Location
Baby's Sex
Sacral Injury
Tailbone Injury
Massage Goals
Flexibility
Improve Fitness
Increase Well-Being
Injury Rehabilitation
Positive Reinforcement
Address Health Issues
Strength Training
Alternative Therapy
Stress Relief
Balance
Massage Frequency
Other
Accident Info
Date of Injury
Which best describes what you are experiencing
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Emotion / Mood
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