Please make sure you answer all required fields to submit this form.If you do not answer all required fields then the form will not be sent.First Name(Required)Last Name(Required)Phone(Required)Email(Required) Birth Date(Required) MM slash DD slash YYYY Health Problems: Have you ever had one of the following health problems? Tension Headache Migraine Headaches TMJ Disorder Chronic Back Pain Chest Pain or Angina Abdominal Pain Pelvic or Genital Pain Arthritis Bone Fracture Concussion Thyroid Disorder Heart Disorder or Heart Attack Lung or Respiratory Disorder Liver Disease or Hepatitis Kidney Disorder or Kidney Stones Urinary or Bladder Disorder Skin Disorder, Eczema, or Hives High Blood Pressure Low Blood Pressure Sexually Transmitted Disease Pre-Menstrual Syndrome Prostate or Vaginal Disorder Epilepsy Cancer Insomnia Asthma Allergies Peptic Ulcer Colitis Diabetes Hypoglycemia Deafness Tinnitus Other Illnesses:Conditions: Do you frequently experience any of the following symptoms? Cold Hands of Feet Swollen Ankles or Feet Stiff, Aching Joints Neck or Shoulder Tension Grinding Your Teeth Ringing in Ears Rapid Heartbeat Excessive Sweating Difficulty Sleeping Over eating or Binge Eating Under eating or Poor Appetite Job Dissatisfaction Sex Life Not Satisfying Lack of Fun or Affection Colds of Flu Sore Throats Dizziness Diarrhea Constipation Nausea, Vomiting Hyperventilation When was your last physical examination?(Required)Accidents: Have you ever been injured in any of the following accidents? Auto Accident Work Accident Accident at Home Other Accidents: OtherItems: Do you have any of the following items more than twice a day? Ice Cream Cup of Coffee Glass of Beer or Wine Liquor or Cocktail Can of Soda Pop Recreational Drug Cigarette Chocolate Medications: Have you ever taken any of the following medications on a regular basis? Aspirin or Tylenol Pain Relieving Drug Sleeping Pill Tranquilizer Antidepressant Blood Pressure Medication Lithium Therapists: Have you seen any of these therapists for your present health problems? Medical Doctor Psychologist Marriage Counselor Psychiatrist Acupuncturist Physical Therapist Massage Therapist Chiropractor Priest, MInister, Rabbi Dentist Nutritionist Healer If you do not see the confirmation page after Submitting this form, you must fix any error(s) on this page otherwise the form will not be sent. Δ
