|
" X " if a current issue or
need, " O" if an old resolved problem but significant. " ? " if unsure |
Check box ↓ |
# |
MUSCULOSKELETAL |
|
|
REPRODUCTIVE / URINARY |
|
1 |
Jaw area |
|
55 |
Bladder infections |
|
2 |
Neck |
|
56 |
Breast pain, cysts, mastectomy,
lactation |
|
3 |
Shoulder pain or restriction |
|
57 |
Incontinence |
|
4 |
Pectoral muscle pain |
|
58 |
Conception - series |
|
5 |
Upper arm |
|
59 |
Uterine or ovarian - fibroids and endometriosis |
|
6 |
Elbow or Forearm |
|
60 |
PMS, Menstual and cramps |
|
7 |
Hands, wrists or thumbs |
|
61 |
Pregnancy - Due Date
____,_____,______ |
|
8 |
Back - Middle |
|
62 |
Pregnancy - during childbirth |
|
9 |
Chest pain or congestion |
|
63 |
Pregnancy - post partum |
|
10 |
Loins (sides above
hips) |
|
64 |
Menopausal and premenopausal |
|
11 |
Back - Lower |
|
65 |
Prostate |
|
12 |
Walking problems |
|
66 |
Sexual organs Female and Male |
|
13 |
Hips |
|
|
CIRCULATORY |
|
14 |
Sacrum (the spine below the hips) |
|
67 |
Angina pain |
|
15 |
Coccyx (tailbone) |
|
68 |
Blood impurities |
|
16 |
Sciatic nerve pain |
|
69 |
Blood Pressure |
|
17 |
Hernia - Inguinal |
|
70 |
Cerebral Haemorrage / Stroke |
|
18 |
Groin pain |
|
71 |
Circulation |
|
19 |
Restless leg syndrome |
|
72 |
Fever |
|
20 |
Leg cramps |
|
73 |
Heart |
|
21 |
Hamstrings or Quads |
|
74 |
Kidney |
|
22 |
Knees |
|
75 |
Varicose Veins |
|
23 |
Calf or shin splints |
|
|
DIGESTIVE |
|
24 |
Ankles |
|
76 |
Abdominal pain |
|
25 |
Feet and Toes |
|
77 |
Constipation |
|
|
SYSTEMIC |
|
78 |
Diarrhea, Hemorrhoids |
|
26 |
A.D.D. or A.D.H.D |
|
79 |
Diverticulosis, IBS, Crohn's |
|
27 |
Arthritis - Mark body with an "A" |
|
80 |
Gall Bladder |
|
28 |
Bursitis - Mark body with a "B" |
|
81 |
Ileocecal valve |
|
29 |
Chronic Fatigue Syndrome |
|
82 |
Liver |
|
30 |
Diabetes |
|
83 |
Indigestion, Nausea, heartburn,
bloating, ulcers, flatulence or belching |
|
31 |
Dyslexia |
|
84 |
Pancreas |
|
32 |
Endocrine / Hormonal |
|
85 |
Weight issues |
|
33 |
Fibromyalgia - Mark body with a "F" |
|
|
RESPIRATORY |
|
34 |
Immune and Endocrine
System |
|
86 |
|
|
35 |
Lymphatic drainage |
|
87 |
Lungs |
|
36 |
Nervous System |
|
88 |
Colds |
|
37 |
Osteoporosis |
|
89 |
Cough |
|
38 |
Reynauds Syndrome |
|
90 |
Diaphragm pain / hiatal hernia |
|
39 |
Sleep problems |
|
91 |
Hay
fever |
|
40 |
Skin condition
- Mark body with a "S" |
|
92 |
Pneumonia |
|
41 |
Swelling - Mark
body with a "SW" |
|
93 |
Throat |
|
42 |
Trembling or Seizures |
|
|
SPIRIT |
|
|
HEAD |
|
94 |
Depression |
|
43 |
Bell's Palsy |
|
95 |
Emotional Overload |
|
44 |
Dizziness |
|
96 |
Short of Energy |
|
45 |
Ear - infections, deafness,
tinnitus, Menier's |
|
97 |
Mental Clarity |
|
46 |
Eye and sight problems |
|
98 |
Stress level ___ high, ___med, ___low |
|
47 |
Hair and scalp |
|
99 |
Meridian or chakra
specific |
|
48 |
Headaches |
|
|
FOR CHILDREN |
|
49 |
Migraines |
|
100 |
Colicy baby and other infant
issues |
|
50 |
Nose, palate |
|
101 |
Bed Wetting - Series |
|
51 |
Sinus conditions |
|
102 |
Anything Else ?↓ |
|
52 |
Teeth - grinding, crowding, or
gums |
|
|
|
|
53 |
Thyroid |
|
|
|
|
54 |
Vertigo |
|
|
|
