Name *

First Name

Last Name

Asthma *

Yes

No

Clinical Depression *

Yes

No

Current Cancer *

Yes

No

Previous Cancer *

Yes

No

Diabetes *

Yes

No

Edema *

Yes

No

Heart Disease *

Yes

No

Heart Attack *

Yes

No

Headaches, Frequent *

Yes

No

High Blood Pressure *

Yes

No

Low Blood Pressure *

Yes

No

HIV+ *

Yes

No

Nerve Pain *

Yes

No

Migraine Headaches *

Yes

No

Multiple Sclerosis *

Yes

No

Osteoporosis *

Yes

No

Paralysis *

Yes

No

Sciatica *

Yes

No

Phlebitis/DVT *

Yes

No

Sleep Disturbance/s *

Yes

No

Stroke *

Yes

No

Seizure/s *

Yes

No

TMJ Disfunction *

Yes

No

Tuberculosis

Yes

No

Varicose Vein/s *

Yes

No

Whiplash *

Yes

No

Tingling in Extremities *

Yes

No

Current Skin Infection *

Yes

No

Blood Clots *

Yes

No

Tendonitis/Bursitis *

Yes

No

Sinus Congestion/Problems *

Yes

No

Menstrual Problems *

Yes

No

Back Pain *

Yes

No

Bone/Joint Pain *

Yes

No

Arthritis *

Yes

No