Name* Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Please answer the following questions:Are you currently taking any medications?YesNoIf yes please explain:Have you had any recent surgical procedure or injury?YesNoIf yes please explain:Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?YesNoIf yes please explain:What is your level of stress? Low 1 2 3 4 5 High Are you allergic to any lotions or oils?YesNoPlease list them:Select any conditions that apply to you, past and present.Please add yours comments to clarify the condition. Please select any of the following conditions that apply to you, past and present. Please add yours comments to clarify the condition below. Musculo-SkeletalMusculo-SkeletalHeadachesJoints stiffness/swellingSpasms/crampsBroken/Fractured bonesStrains/SprainsBack, hip painShoulder, neck, arm, hand painLeg, foot painChest, ribs, abdominal painProblems walkingJaw pain/TMJTendonitisBursitisArthritisOsteoporosisScoliosisOther: ______________________________________Circulatory/RespiratoryDizzinessShortness of breathFaintingCold feet or handsCold sweatsStroke Heart conditionAllergiesAsthmaHigh blood pressureLow Blood PressureAneurysmOther: ______________________________________DigestiveIndigestionConstipationIntestinal gas/bloatingDiarrheaIrritable bowel syndromeChron’s DiseaseColitisOther: ______________________________________Nervous SystemNumbness/tinglingFatiqueSleep DisordersUlcersParalysisHerpes/ShinglesCerebral PalsyEpilepsyChronic FatigueMultiple SclerosisMuscular DistrophyParkinson's DiseaseOther: ______________________________________Reproductive SystemPregnancyOther: ______________________________________OtherLoss of appetiteDepressionDifficulty concentratingHearing impairedVisually impairedDiabetesFibromyalgiaPost Polio SyndromeCancerTuberculosisWater/day _______________Alcohol/day _____________Nicotine/day _____________Caffeine/day _____________Other: ______________________________________Additional Comments:I understand that a Structural Integrator does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand Structural Integration is a manual connective tissue therapy and the therapist will work on muscles and fascia in a specific way to relieve tension and increase wellness. I understand that Structural Integration is not a substitute for medical treatment or medications. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status. I understand that a 24-hour cancellation is required for scheduled appointments. Consent Client’s SignatureDate MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
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