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General Health
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Conditions
Energy
Does your energy fluctuate?
Is your energy constant?
When is your energy highest?
When is your energy lowest?
What is your energy level upon awakening?
How long do you sleep on average?
Do you struggle with insomnia?
Comments
Does your energy fluctuate?
Is your energy constant?
When is your energy highest?
When is your energy lowest?
What is your energy level upon awakening?
How long do you sleep on average?
Do you struggle with insomnia?
Vocal Health
Vocal Fatigue
Hoarseness
Complete Loss of Voice
Loss of Vocal Range
Pain
Difficulty Swallowing
Difficultly Speaking
Difficulty Singing
Acid Reflux
Medications
Whiplash
Hydration
Diet
Diet Type
Diet Moderation
Intermittent Fasting
Exercise
Comments
Vocal Fatigue
Hoarseness
Complete Loss of Voice
Loss of Vocal Range
Pain
Difficulty Swallowing
Difficultly Speaking
Difficulty Singing
Acid Reflux
Medications
Whiplash
Hydration
Diet
Diet Type
Diet Moderation
Intermittent Fasting
Exercise
Well Being
Exercise
Flexibility
Range of Motion
Comments
Exercise
Flexibility
Range of Motion
TMJ (Jaw)
Jaw Pain
Clicking
Locking
Difficulty Chewing
Clenching
Morning Stiffness
Ear Ringing
Ear Stuffiness
Ear Pressure
Ear Blockage
Difficulty Opening Jaw
Grinding
Comments
Jaw Pain
Clicking
Locking
Difficulty Chewing
Clenching
Morning Stiffness
Ear Ringing
Ear Stuffiness
Ear Pressure
Ear Blockage
Difficulty Opening Jaw
Grinding
Treatment Goals
Pain Relief
Stress Relief
Support in Healing/Recovery
Rehabilitation
Health Advice for Healing
Improve Well Being
Improve Symptoms
Improve Lifestyle
Other
Comments
Pain Relief
Stress Relief
Support in Healing/Recovery
Rehabilitation
Health Advice for Healing
Improve Well Being
Improve Symptoms
Improve Lifestyle
Other
Which best describes what you are experiencing
Pain
Mild
Getting Worse
Ache
Moderate
Staying the Same
Tension
Disabling
Getting Better
Discomfort
Constant
Imbalance
Intermittent
No Change
Increases with Activity
Decreases with Activity
Other
Comments
Pain
Mild
Getting Worse
Ache
Moderate
Staying the Same
Tension
Disabling
Getting Better
Discomfort
Constant
Imbalance
Intermittent
No Change
Increases with Activity
Decreases with Activity
Other
Area of Complaint
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Left Groin
Right Groin
Left Gluteal
Right Gluteal
Sacrum
Tailbone (coccyx)
Right Thigh
Left Thigh
Right Calf
Left Calf
Neck
Upper Back
Mid Back
Low Back
Comments
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Left Groin
Right Groin
Left Gluteal
Right Gluteal
Sacrum
Tailbone (coccyx)
Right Thigh
Left Thigh
Right Calf
Left Calf
Neck
Upper Back
Mid Back
Low Back
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Comments
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Other Headaches
Family History
Arthritis
Cardiovascular
Respiratory
Cancer
Diabetes
Comments
Arthritis
Cardiovascular
Respiratory
Cancer
Diabetes
Endocrine
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Prostate Condition
Other Endocrine
Blood Sugar Managed?
Adrenal Fatigue
Comments
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Prostate Condition
Other Endocrine
Blood Sugar Managed?
Adrenal Fatigue
Hearing
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Comments
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Immune
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Sjogren's Syndrome
Other Immune
HIV/Aids
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Sjogren's Syndrome
Other Immune
HIV/Aids
Musculoskeletal
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Carpal Tunnel Syndrome
Plantar Fasciitis
Dupuytren's Contracture
Chronic Myofascial Pain Syndrome
Chronic Fatigue Syndrome
Spondylolisthesis
Ehlers-Danlos Syndrome
Other Musculoskeletal
Whiplash
Temporomandibular Joint Dysfunction
Degenerative Disk Disease
Torticollis
Baker's Cyst
Recti Diastasis
Comments
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Carpal Tunnel Syndrome
Plantar Fasciitis
Dupuytren's Contracture
Chronic Myofascial Pain Syndrome
Chronic Fatigue Syndrome
Spondylolisthesis
Ehlers-Danlos Syndrome
Other Musculoskeletal
Whiplash
Temporomandibular Joint Dysfunction
Degenerative Disk Disease
Torticollis
Baker's Cyst
Recti Diastasis
Neurological
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Other Neurological
Chiari Malformation
Syringomyelia
Tethered Cord
Cerebrospinal Fluid Leak
Dural Ectasia
Bell's Palsy
Peripheral Neuropathy
Comments
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Other Neurological
Chiari Malformation
Syringomyelia
Tethered Cord
Cerebrospinal Fluid Leak
Dural Ectasia
Bell's Palsy
Peripheral Neuropathy
Miscellaneous
Vision Problems
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Music Preference
Comments
Vision Problems
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Music Preference
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