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Headaches/Migraine Neck Pain Arms/Shoulder Upper Back Mid Back Lower Back Hips Sciatica Legs Elbows Knees Wrists/Hands Past History:
Contact Lenses?_______ Hearing Aids?_______ Dentures?_______ Please Indicate and List Any Medical Problems or Conditions Recent Head Injury -- Stroke, Aneurysm, Cerebral Hemorrhage, other Recent Injury – whiplash, sprain, bruise, other Skin Condition – acne, rash, allergies, skin cancer, other Lymphatic Condition – swollen glands, lymphoma, other Circulatory Condition – heart disease, varicose veins, phlebitis, arteriosclerosis, other Neurological Condition – sciatica, numbness/tingling, stroke, epilepsy, other Back Problems – pain or stiffness, sacroiliac problems, other Joint Problems – pain or stiffness, osteoarthritis, rheumatoid arthritis, other Bone Conditions – osteoporosis, previous fractures, cancer, other Headaches – migraines, PMS, tension, sinus, other Emotional Difficulties – depression, anxiety, other Stress (explain) Previous surgery (type and date Other Current Medications Doctor/Therapist_____________________________________________ Phone _____________________________ You have my permission to contact my health care provider(s) if warranted.
Arthritis Balance Disorders Lower Back Pain Varicose Veins Insomnia Hemorrhoids Diabetes Headaches Asthma High Blood Pressure Bronchitis Shingles Chest Congestion Colds Anxiety Stomach Problems Circulatory Disease Joint and Muscle Problems Stress Nerve Problems Rheumatism Fibrositis Sciatica Lumbago Life-changing benefits, beyond the tub The therapeutic benefits of a Safe Step Tub can help you feel better, sit more comfortably and move more easily.
Heart Disease Surgery Immunity Related Disorder High Blood Pressure Herpes Simplex Insomnia Hospitalization Whiplash Hypertension Hepatitis Asthma Migraines Carpel Tunnel Angina Contagious Disease Sciatica Phlebitis/Thrombosis Pregnancy Stroke Fibromyalgia Repetitive Strain Injury Varicose Veins Disc Problems Other:
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As another test of Jacob’s faith and earnestness, instead of the desired blessing came a severe affliction— prob ably what is now known as sciatica, a most painful affliction of the sciatic nerve.