101. LOW BACK PAIN 126. DISEASE □ □ □ □ 102. PAINFUL JOINTS 127. CANCER □ □ □ □ 103. MUSCLE 128. MUSCLE, BONE OR □ □ □ □ ACHE/SOARNESS NERVE DISEASE 104. SPINAL CURVATURE 129. LUNG DISEASE □ □ □ □ 105. ARTHRITIS 130. □ □ □ □ 131. ARTHRITIS EXERCISE □ 132. SEIZURE/ STROKE 106. NONE □ □ □ □ 107. 1- 2 TIMES A WEEK □ □ □ 108. 3- 5 TIMES A WEEK □ □ □ 109. 6- 7 TIMES A WEEK □ □ □ HABITS 110. SMOKING ___# □ □ □ PACKS/DAY 111. DRINKING ALCOHOL □ □ □ MEN & 112. RECREATIONAL □ □ □ 87. BREAST LUMP OR PAIN □ □ □ DRUG USE 113. CAFFEINE □ □ □ NEUROLOGICAL 114. SOFT DRINKS □ □ □ 88. WEAKNESS 115. ARTIFICIAL □ □ □ □ □ □ 89. TWITCHING SWEETNER □ □ □ 90. TREMOR □ □ □ 91. HEADACHE □ □ □ TRAUMA 92. FAINTING □ □ □ 116. CAR ACCIDENT □ □ □ 93. DIZZINESS □ □ □ 117. MAJOR FALL □ □ □ 94. CONVULSIONS □ □ □ 118. BROKEN BONES □ □ □ 95. EPILEPSY/ SEIZURES □ □ □ 119. HEAD TRAUMA □ □ □ 96. NUMBNESS/ □ □ □ 120. SPORTS □ □ □ TINGLING FAMILY HISTORY 97. ARM/ LEG PAIN □ □ □ 121. DIABETES □ 98. MENTAL DISORDER □ □ □ 122. THYROID DISEASE/ □ MUSCULOSKELETAL GOITER 99. NECK STIFFNESS/ □ □ □ 123. TOBERCULOSIS □ PAIN 124. KIDNEY DISEASE □ 100. PAIN BETWEEN □ □ □ 125. HIGH PRESSURE □ SHOULDERS
MEN & 87. □ □ □ BREAST LUMP OR PAIN NEUROLOGICAL 88. □ □ □ WEAKNESS 89. □ □ □ TWITCHING 90. □ □ □ TREMOR 91. □ □ □ HEADACHE 92. □ □ □ FAINTING 93. □ □ □ DIZZINESS 94. □ □ □ CONVULSIONS 95. □ □ □ EPILEPSY/ SEIZURES 96. □ □ □ NUMBNESS/ TINGLING 97. □ □ □ ARM/ LEG PAIN 98. □ □ □ MENTAL DISORDER MUSCULOSKELETAL 99. □ □ □ NECK STIFFNESS/ PAIN 100. □ □ □ PAIN BETWEEN SHOULDERS 101. □ □ □ LOW BACK PAIN 102. □ □ □ PAINFUL JOINTS 103. □ □ □ MUSCLE ACHE/SOARNESS 104. □ □ □ SPINAL CURVATURE 105. □ □ □ ARTHRITIS EXERCISE 106. □ □ □ NONE 107. □ □ □ 1- 2 TIMES A WEEK 108. □ □ □ 3- 5 TIMES A WEEK 109. □ □ □ 6- 7 TIMES A WEEK HABITS 110. □ □ □ SMOKING ___# PACKS/DAY 111. □ □ □ DRINKING ALCOHOL 112. □ □ □ RECREATIONAL DRUG USE 113. □ □ □ CAFFEINE 114. □ □ □ SOFT DRINKS 115. □ □ □ ARTIFICIAL SWEETNER TRAUMA 116. □ □ □ CAR ACCIDENT 117. □ □ □ MAJOR FALL 118. □ □ □ BROKEN BONES 119. □ □ □ HEAD TRAUMA 120. □ □ □ SPORTS FAMILY HISTORY 121. □ DIABETES 122. □ THYROID DISEASE/ GOITER 123. □ TOBERCULOSIS 124. □ KIDNEY DISEASE 125. □ HIGH PRESSURE 126. □ DISEASE 127. □ CANCER 128. □ MUSCLE, BONE OR NERVE DISEASE 129. □ LUNG DISEASE 130. □ 131. □ ARTHRITIS 132. □ SEIZURE/ STROKE
Packet-New-Patient-Information.docx