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Client Information
First Name
Last Name
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Do you have a family History of any ofthe following?
Osteoporosis
Heart Disease
Stroke
Obesity
Cancer
Diabetes
Personal Health History
Osteoporosis
Heart Disease
Stroke
Osteoarthritis
Cancer
Diabetes
Heart Surgery
Heart Attack
Chest Pain at r3est
Chest Pain during activity
Irregular Heart beat
Pacemaker
High Blood Pressure
High Cholesterol
Rheumatoid Arthritis
Asthma
Emphysema
Currently Pregnant
Neck, Knee , back issues
Balance Issues
Recent Surgery
Hearing or Vision issues
Shoulder issues
Dizziness
Therapy in the past 2 years
Date
Initials
I confirm that the information given in this form is true
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