Name

First Name

Last Name

Acute Infectious Disease

Yes

No

Varicose Veins

Yes

No

Injury

Yes, In Neck

Yes, In Back

No

Jaw or Ear Pain

Yes, In Jaw

Yes, In Ear

No

Fainting or Dizziness

Yes, Fainting

Yes, Dizziness

No

Headaches or Migraines

Yes

No

Blood Pressure

High

Low

Normal

Skin Conditions

Yes

No

Fungal Infections

Yes

No

Nervous Disorders

Yes

No

Phlebitis / Circulatory Problems

Yes

No

Whiplash

Yes

No

Rheumatoid Arthritis

Yes

No

Osteoarthritus

Yes

No

Kidney Disease

Yes

No

Diabetes

Yes

No

Asthma / Respiratory

Yes

No

Fibromyalgia

Yes,

No

Crohn's Disease

Yes

No

Pelvic Inflammatory Disease

Yes

No

Epilepsy

Yes

No

Cancer

Yes

No

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Yes

No

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No

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