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Patient Form

HOW CAN WE HELP YOU?

 
What does it feel like? (tick where appropriate) NumbnessSharpTinglingShootingStiffnessBurningDullThrobbingAchingStabbingCrampingSwellingNagging
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HEALTH & ILLNESS HISTORY

Please tick the box beside any condition that you have or have had. AIDS/HIVAlcoholismAnxietyArteriosclerosisArthritisAsthma/AllergiesBack PainCardiovascular IssuesCancerCirculation IssuesChildhood IllnessDepressionDiabetesDigestive Issues(Constipation/Diarrhoea/IBS)Elbow/Wrist/Hand IssuesThyroid IssuesFoot/Ankle IssuesGoutHeadaches/MigrainesHeart DiseaseHepatitisHip IssuesImmune IssuesLymphatic IssuesMultiple SclerosisNeck PainReproductive IssuesRinging in EarsScoliosisShoulder IssuesStrokeTMJ IssuesUrinary IssuesOsteoporosis

ALLERGIES, MEDICATIONS & SUPPLEMENTS

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