New client intake paperwork

Name *

First Name

Last Name

Do you have or have you had: *

High blood pressure

Glaucoma

Osteoporosis

Seizures

Diabetes

Rheumatoid arthritis

Anemia

Heart problems

Asthma

Other breathing problems

Dizziness, vertigo or loss of balance

Unexplained falls or fractures

Hearing difficulty

Hernia/rupture

Unstable/ "trick" joint(s)

Hearing difficulty

Metal implants/artificial joints

Bladder or bowel control problems

Pinched nerves or disc problems

Cancer

Broken bones

Allergies

Blood thinners

Neurological diseases

Headaches

Vision difficulties

Chest pain

Shortness of breath

Night sweats

Joint swelling

Traumatic auto accidents

Major surgeries

Other chronic conditions:

Hysterectomy

Menopausal challenges

Caesarean delivery

Early termination of menses

Do any of the following currently apply? *

Back problems

Hernia

Joint problems

Epilepsy

Arthritis

Low blood pressure

Hypoglycemia

Chronic fatigue

Anxiety/depression