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Conditions
Female Health
First Period
Last Period
Number of Pregnancies
Number of Live Births
Last PAP test
Abnormal PAP test
Irregular Periods
Menstrual Cycle Length
Menstrual Period Length
Menstrual Cramping
Heavy Bleeding
Endometriosis
Infertility
Unwanted hair growth
Premenstrual Syndrome
Breast Cancer
Ovarian Cancer
Osteoporosis
Current Menopausal Concerns
Currently Pregnant
Birth Control Method
Implants
Fibroids
PCOS
Uterine Polyps
Spotting
Dark Blood
Clots
Brown Spotting
Pencil Like Stool
Heaviness in Pelvis
Urinary Incontinence
Pelvic Organ Prolaps
Pelvic Floor Injury
Scar Tissue
Pain with Sex
Pelvic Pain
Comments
First Period
Last Period
Number of Pregnancies
Number of Live Births
Last PAP test
Abnormal PAP test
Irregular Periods
Menstrual Cycle Length
Menstrual Period Length
Menstrual Cramping
Heavy Bleeding
Endometriosis
Infertility
Unwanted hair growth
Premenstrual Syndrome
Breast Cancer
Ovarian Cancer
Osteoporosis
Current Menopausal Concerns
Currently Pregnant
Birth Control Method
Implants
Fibroids
PCOS
Uterine Polyps
Spotting
Dark Blood
Clots
Brown Spotting
Pencil Like Stool
Heaviness in Pelvis
Urinary Incontinence
Pelvic Organ Prolaps
Pelvic Floor Injury
Scar Tissue
Pain with Sex
Pelvic Pain
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?
Well Being
Exercise
Sports
Flexibility
Range of Motion
Hobbies
Interests
Drinking
Smoking
Caffeine
Mobility/Walking Aids
Comments
Exercise
Sports
Flexibility
Range of Motion
Hobbies
Interests
Drinking
Smoking
Caffeine
Mobility/Walking Aids
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
Male Health
Difficulty Maintaining Erection
Difficulty Obtaining Erection
Painful Ejaculation
History of Back Injury
PSA Test Results
Sperm Count Results
Urinary Stream Changes
Painful Urination
Nocturnal Urination
Family History of Prostate Disease
Family History of Prostate Cancer
History of STD
Difficulty Experiencing Orgasm
Comments
Difficulty Maintaining Erection
Difficulty Obtaining Erection
Painful Ejaculation
History of Back Injury
PSA Test Results
Sperm Count Results
Urinary Stream Changes
Painful Urination
Nocturnal Urination
Family History of Prostate Disease
Family History of Prostate Cancer
History of STD
Difficulty Experiencing Orgasm
Brain Disorders
Acute Stress Disorder
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
ADD
ADHD
Autism
Asperger Syndrome
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Comments
Acute Stress Disorder
Agoraphobia
Anorexia Nervosa
Antisocial Personality Disorder
ADD
ADHD
Autism
Asperger Syndrome
Bipolar Disorder
Borderline Personality Disorder
Bulimia Nervosa
Claustrophobia
Depression
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Obsessive Compulsive Personality Disorder
Panic Disorder
PTSD
Schizophrenia
Sleep Disorder
Social Anxiety Disorder
Eating Habits
Breakfast
Lunch
Dinner
Snacks
Comments
Breakfast
Lunch
Dinner
Snacks
Emotion / Mood
Anxiety
Fear
Sadness
Depression
Grief
Despair
Negative Self-Talk
Anger
Other Emotions
PTSD
Stress Response and Coping Strategies
Overall mood and energy level
Rate the stress in your life (1-10)
Physical Abuse History
Mental Abuse History
Comments
Anxiety
Fear
Sadness
Depression
Grief
Despair
Negative Self-Talk
Anger
Other Emotions
PTSD
Stress Response and Coping Strategies
Overall mood and energy level
Rate the stress in your life (1-10)
Physical Abuse History
Mental Abuse History
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
Blood
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Other Blood
Comments
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Other Blood
Cardiovascular
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Other Cardiovascular
Postural Orthostatic Tachycardia Syndrome
Swelling
Comments
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Other Cardiovascular
Postural Orthostatic Tachycardia Syndrome
Swelling
Endocrine
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Other Endocrine
Temiskaming Diabetes Program
Blood Sugar Managed?
Wound Healing Status?
Adrenal Fatigue
Comments
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Other Endocrine
Temiskaming Diabetes Program
Blood Sugar Managed?
Wound Healing Status?
Adrenal Fatigue
Gastrointestinal
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Other Gastrointestinal
Gastroparesis
Comments
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Other Gastrointestinal
Gastroparesis
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
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Sjogren's Syndrome
Other Immune
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Comments
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Other Kidney
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
Temporomandbular 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
Temporomandbular 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
Reproductive
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Other Reproductive
Prostatitis
Enlarged Prostate
Comments
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Other Reproductive
Prostatitis
Enlarged Prostate
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Other Respiratory
Comments
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Other Respiratory
Skin
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Other Skin
Eczema
Non-Surgical Scars
Surgical Scars
Mature Skin
Dry Skin
Oily Skin
Combination Skin
Sensitive Skin
Sun Damage
Using RETIN A
Using ALPHA Hydroxy Acids
Allergic to Iodine
Comments
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Other Skin
Eczema
Non-Surgical Scars
Surgical Scars
Mature Skin
Dry Skin
Oily Skin
Combination Skin
Sensitive Skin
Sun Damage
Using RETIN A
Using ALPHA Hydroxy Acids
Allergic to Iodine
Miscellaneous
Other Medical Conditions
Comments
Other Medical Conditions
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