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Genetics
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TMJ (Jaw)
Ear Pressure
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Health Questions
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Epilepsy
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Past Heart Surgery
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Infant
Tongue Tie Support
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Gas
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Torticollis
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Abdominal Conditions
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Post Surgical Support
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Allergies
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Colic
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Stress
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Constipation
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Other Conditions
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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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Right Leg
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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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Headaches
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Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Cluster
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Other Headaches
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Musculoskeletal
Dupuytren's Contracture
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Osteomalacia
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Torticollis
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Myasthenia Gravis
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Adhesive Capsulitis
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Ankylosing Spondylitis
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Bone Disease
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Gout
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Ehlers-Danlos Syndrome
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Paget Disease
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Osteoarthritis
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Whiplash
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Baker's Cyst
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Compartment Syndrome
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Joint Stiffness / Swelling
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Psoriatic Arthritis
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Arthritis
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Sinus Problems
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Bone or Joint Disease
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Dislocation
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Plantar Fasciitis
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Scleroderma
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Osteoporosis
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Broken Bone / Fracture
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Fracture
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Jaw Pain (TMJD)
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Recti Diastasis
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Scoliosis
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Fibromyalgia
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Tendonitis/Bursitis
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Carpal Tunnel Syndrome
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Chronic Fatigue Syndrome
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Hereditary/Congenital Deformity
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Spasms / Cramps
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Strain/Sprain
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Chronic Myofascial Pain Syndrome
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Joint Injury
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Spondylolisthesis
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Amyotrophic Lateral Sclerosis (ALS)
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Artificial Joints / Special Equipment
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Degenerative Disk Disease
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Osgood-Schlatter Disease
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Temporomandibular Joint Dysfunction
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Muscular Dystrophy
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Other Musculoskeletal
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Neurological
Loss of Sensation
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Multiple Sclerosis
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Cerebral-vascular Accident
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Stroke
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Dural Ectasia
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Transient Ischemic Attacks (TIA)
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Tethered Cord
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Twitching of Face
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Epilepsy
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Vertebral and Spinal Cord Injury
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Fatigue
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Shingles
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Numbness
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Huntington Disease
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Fibromyalgia
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Dizziness
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Burning
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Bell's Palsy
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Brain Disorder
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Peripheral Neuropathy
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Sciatic Pain
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Tingling
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Carpal Tunnel
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Chronic Pain Disorder
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Post Polio Syndrome
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Cerebral Palsy
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Stabbing
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Cerebrospinal Fluid Leak
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Brain Injury
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Shingles / Herpes
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Parkinsons
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Chiari Malformation
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Cerebral Vascular Accident (Stroke)
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Sleeping Disorders
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Herniated Disc
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Seizure Disorder
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Syringomyelia
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Other Neurological
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Miscellaneous
Dentures
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Hearing Impaired
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Vision Problems
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Liver Disease
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Vision Loss
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ADHD
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Loss of Balance
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Insomnia
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Autism
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Mental Health Issues
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Music Preference
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Contact Lens
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Surgical Pins or Wire
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Upper Respiratory Infection
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Dental Bridge
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Visually Impaired
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Dental Implants
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Weakened Immune Function
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
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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Abdominal Cramping
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Edema/Swelling
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Leg Cramps
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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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Stroke
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Carpal Tunnel Syndrome
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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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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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Allergy
Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Environmental
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