Detailed Medical History Questionnaire
Because an injury sustained as a teenager could be the reason for an ache today..
This information is private and confidential.
Name
email
Head and Neck
Clear selection
Neurological or Limbic
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Spine/ Upper Back
Clear selection
Cardiovascular
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Respiratory
Lymphatic
Clear selection
Shoulders
Clear selection
Arms and Hands
Clear selection
Organ Function
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Digestive
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Reproductive/ Urologic
Clear selection
Spine - Lower
Clear selection
Hips/ Pelvis
Clear selection
Knees
Clear selection
Foot/ Ankle
Clear selection
Space to elaborate on or add injuries not included above
Thank you
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