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Client Intake Form
Health History
Cardiovascular
Congestive heart failure
Heart disease
Low blood pressure
Poor circulation
Varicose veins
Embolism
Hemophilian
Pacemaker
Stroke
Family history
Heart attack
High blood pressure
Phlebitis
Thrombosis
Respiratory
Asthma
Emphysema
Bronchitis
Shortness of breath
Tuberculosis
Chronic cough
Sinusitis
Family history
Smoker
Head & Neck
Dizziness
Hearing loss
Vision loss
Ear problems
Jaw pain (TMJ)
Vision problems
Headaches
Migraines
Miscellaneous
Anxiety
Diabetes
HIV/AIDS
Cancer
Digestive conditions
Stress
Depression
Fibromyalgia
Neurological
Epilepsy
Sensory loss/change
Multiple sclerosis
Sciatica
Numbness/tingling
Seizures
Musculoskeletal
Arthritis
Osteoporosis
Artificial joint
Surgical pin/wire
Bursitis
Tendonitis
Reproductive
Given Birth
Gynecological Problems
Pregnant
Skin
Bruise Easily
Skin Irritations
Skin Conditions
Skin Infections
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