Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

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Do you have any of these health conditions?

Please give details of anything you check in the field below. No such thing as TMI here.

I'm a smoker

I have had surgery/surgeries (list date(s) and details below)

I have had a joint replacement (list date of replacement(s) and indicate which joint below)

I am pregnant (list due date below)

I experience incontinence

I have osteoporosis/osteopenia/spinal stenosis

I have blood pressure issues

I suffer migraines

I have sinus issues

I have asthma

I have a blood disorder

I suffer anxiety and/or depression

I have arthritis/joint swelling/bursitis

I have an autoimmune disorder

I have numbness/tingling

I have an addiction

I have an eating disorder

I am currently under a physician's care

I take medications (please list below)

I take herbal supplements (please list below)

I use THC

I use CBD

I have balance issues

I have vertigo

I have heart disease

I have had a stroke

I have lung disease

I have low back pain

I think I am carrying excess weight

I have epilepsy/experience siezures

I have vision problems

I have joint pain/swelling

I have poor circulation

I have scoliosis

I have diabetes

I have allergies (please list below)

I have varicose veins

I grind my teeth/have jaw tension