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Confidential Medical Information Online Form

Full Name:

 * required
Confidential Medical Information
State current problem(s):
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1 = NO PAIN and 10 = WORST PAIN   

What has been your average pain over the past few days:

 
Are you currently being treated by:
Another Therapist
 
Chiropractor
 
Home Health Agency
 
   
Major surgeries that affect exercise:
Allergies:
List current medications:
Request information on:
Check if you currently have or previously had any of the following:
Arthritis
High Blood Pressure
Asthma
Gout
Cancer
Seizures
Circulation Problems
Stroke
Diabetes
Ulcers
Heart Problems
Other Illnesses

Please specify: