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General Health
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Current Treatment
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Medications
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Additional Info
Conditions
TMJ (Jaw)
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Clicking
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Difficulty Opening Jaw
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Locking
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Grinding
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Morning Stiffness
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Ear Ringing
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Energy
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Do you struggle with insomnia?
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Does your energy fluctuate?
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Is your energy constant?
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Treatment Goals
Health Advice for Healing
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Improve Well Being
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Improve Symptoms
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Well Being
Exercise
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Range of Motion
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Vocal Health
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Difficultly Speaking
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Difficulty Singing
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Pain
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Diet
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Diet Type
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Intermittent Fasting
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Medications
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Acid Reflux
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Whiplash
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Hydration
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Exercise
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Female Health
First Period
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Last Period
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Number of Pregnancies
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Number of Live Births
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Irregular Periods
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Menstrual Cycle Length
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Menstrual Period Length
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Menstrual Cramping
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Endometriosis
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Unwanted hair growth
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Premenstrual Syndrome
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Breast Cancer
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Current Menopausal Concerns
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Currently Pregnant
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Birth Control Method
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Implants
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low 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 Groin
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Right Groin
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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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Headaches
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Rebound
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Headaches
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Chronic Daily Headache
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Tension
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Other Headaches
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Neurological
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Stroke
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Tethered Cord
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Peripheral Neuropathy
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Tingling
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Sciatic Pain
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Cerebrospinal Fluid Leak
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Loss of Sensation
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Seizure Disorder
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Cerebral Palsy
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Stabbing
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Dural Ectasia
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Transient Ischemic Attacks (TIA)
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Parkinsons
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Herniated Disc
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Cerebral-vascular Accident
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Vertebral and Spinal Cord Injury
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Multiple Sclerosis
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Huntington Disease
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Epilepsy
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Brain Disorder
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Chiari Malformation
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Chronic Pain Disorder
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Shingles
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Numbness
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Syringomyelia
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Brain Injury
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Dizziness
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Bell's Palsy
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Other Neurological
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Skin
Skin Conditions
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Hypersensitive Reactions
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Acne
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Bruise Easily
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Skin Irritations
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Musculoskeletal
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Amyotrophic Lateral Sclerosis (ALS)
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Chronic Fatigue Syndrome
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Jaw Pain (TMJD)
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Artificial Joints / Special Equipment
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Osgood-Schlatter Disease
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Muscular Dystrophy
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Spondylolisthesis
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Ankylosing Spondylitis
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Tendonitis/Bursitis
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Osteomalacia
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Myasthenia Gravis
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Bone Disease
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Paget Disease
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Compartment Syndrome
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Psoriatic Arthritis
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Degenerative Disk Disease
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Gout
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Torticollis
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Osteoarthritis
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Dislocation
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Sinus Problems
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Carpal Tunnel Syndrome
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Scleroderma
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Plantar Fasciitis
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Baker's Cyst
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Fracture
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Scoliosis
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Dupuytren's Contracture
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Whiplash
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Arthritis
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Recti Diastasis
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Osteoporosis
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Hereditary/Congenital Deformity
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Fibromyalgia
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Strain/Sprain
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Chronic Myofascial Pain Syndrome
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Other Musculoskeletal
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Cardiovascular
Raynaud Disease
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Varicose Veins
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Low Blood Pressure
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High Blood Pressure
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Blood Pressure
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Cold Feet
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Valve Disorders
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Blood Clots
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Cold Hands
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Cardiac Arrhythmia
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Lymphedema
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Hearing
Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Conductive Hearing Loss
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Meniere Disease
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Motion Sickness
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Other Hearing
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Blood
Anemia
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High Cholesterol
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Gastrointestinal
Stomach Disorder
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Digestive Conditions
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Irritable Bowel Syndrome
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Constipation
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Diverticulitis
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Reproductive
Ovarian Cysts/Tumors
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Premenstrual Syndrome
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Menopause
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Ectopic Pregnancy
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Uterine Disorder
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Endometriosis
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Endocrine
Adrenal Fatigue
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Diabetes
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Prostate Condition
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Blood Sugar Managed?
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Acute Pancreatitis
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Hyperthyroidism
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Hypothyroidism
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Other Endocrine
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Respiratory
Asthma
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Shortness of Breath
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Immune
Hodgkin Lymphoma
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Sjogren's Syndrome
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HIV/Aids
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Infectious Mononucleosis
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Allergies
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Anaphylaxis
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Leukemia
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Lupus
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Non-Hodgkin Lymphoma
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Cancer
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Rheumatoid Arthritis
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Other Immune
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Diabetes
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Cancer
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Kidney
Urinary Incontinence
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Kidney Stones
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Miscellaneous
Surgical Pins or Wire
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Mental Health Issues
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Vision Problems
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Music Preference
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Insomnia
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Other Medical Conditions
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Other Diagnosed Diseases
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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