Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Phone

(###)

###

####

Medical History

Do you have any history of the following? Please check all that apply.

Osteoarthritis

Rheumatoid Arthritis

Diabetes

Thyroid Problems

Glandular Problems

Skin Conditions

Disease of any Internal Organs

Cancer

Radiation /Chemotherapy

Communicable Disease

Dizziness

Fainting

Anticoagulant Therapy

High Dose Steroid Therapy

Recent weight loss/gain

Allergies

Breathing Disorders

Osteoporosis

Scoliosis

Other Bone/Joint Issues

Muscular Disorder

Stroke

Epilepsy

Multiple Sclerosis

Anxiety or Depression

Other Neurological Disorders

Heart Attack

Pacemaker

Angina

High/Low Blood Pressure

Other Heart Problems

Are you currently pregnant?

Yes

No