Thermal Imaging History Form

Thermal Imaging History Form

May 7, 2024

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*

First Participant's Date of Birth*

First Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Breast Thermography Study Client Disclosure Breast thermography is a non-contact, private and non-invasive procedure. The value of thermography as a study tool is its ability to measure skin temperature changes. It offers men and women information that no other procedure can provide regarding breast health. Breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography, mammography or breast ultrasounds are complementary procedures; one test does not replace the other. Breast thermography is meant to be used in addition to other tests or procedures. Thermography captures and records temperature variations on the skin, which provides vital information directly influenced by complex metabolic and vascular activity. This information does not in any way suggest diagnosis and/or treatment. Studies show that the patient benefits when multiple tests are used together. This multimodal approach includes breast self-examinations, physical breast exams by a doctor, mammography, ultrasound, MRI, thermography, and other tests that may be ordered by your doctor. A reported “Elevated Level of Concern” finding does not indicate that it is suspicious for any specific disease. However, any suspicious finding will be accompanied with a strong and intentional recommendation for further clinical evaluation. If you detect a lump or any other change in your breast before your next thermogram study, consult your doctor immediately. Notice to clients presenting with previously diagnosed cancer: Thermography interpretation in your report does not include information or recommendations related to the measured changes of disease beyond skin temperature changes and patterns. As there is no single known test capable of monitoring all biological influences of the complex disease generally diagnosed as cancer, continued monitoring with available additional testing as recommended by your personal physician is strongly advised. Your Thermographer may not be a licensed medical professional. Your Thermographer cannot interpret your images or advise or prescribe to you based on your images. Your thermographer can ask health history questions as well as educate you on general breast health.

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

First Participant's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Second Participant's Name

First Name*

Middle Name

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Third Participant's Name

First Name*

Middle Name

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Fourth Participant's Name

First Name*

Middle Name

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Fifth Participant's Name

First Name*

Middle Name

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Sixth Participant's Name

First Name*

Middle Name

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Seventh Participant's Name

First Name*

Middle Name

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Eighth Participant's Name

First Name*

Middle Name

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Ninth Participant's Name

First Name*

Middle Name

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Tenth Participant's Name

First Name*

Middle Name

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Parent or Guardian's Email Address

Email*

Confirm Email*

Check to receive information, news, and discounts by e-mail.

Participant's Address

Address Line 1:*

Street address, P.O. box, company name, c/o

Address Line 2:

Apartment, suite, unit, building, floor, etc.

Country:*

City:*

State/Province:*

Zip/Postal:*

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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Information

Relationship status

Occupation

Hours per week

Referred by

Head & Neck

Do you suffer from headaches?*

Yes

Do you have know allergies? *

Yes

Do you have TMJ or does your jaw click? *

Yes

Do you currently have a cold? *

Yes

Are you being treated for a Thyroid disorder? Yes No *

Yes

Do you have neck pain? *

Yes

Do you have upper back pain? *

Yes

Do you have a known history of coritid artery disease? *

Yes

Do you have a family history of stroke?*

Yes

Do you currently suffer with sinus problems?*

Yes

Do you have history of dental problems? *

Yes

Dental Problems:

Root Canals

Gum Disease

Non-Replaced Extractions

Mercury Fillings

Implants

Dentures

Have you had a dental cleaning in the past 7 days? *

Yes

Have you been diagnosed with elevated cholesterol?*

Yes

Do you have any special concerns or are there any details related to the information above?

Breast

Have you experienced any of these breast symptoms?

Pain or Tenderness

Left

Right

Lumps

Left

Right

Change in breast size

Left

Right

Areas of skin changes, thickening or dimpling

Right

Left

Excretion or changes of the nipple

Left

Right

Are any of the above symptoms cycle related? *

Yes

Are you still having your periods? *

Yes

Have you had a surgical hysterectomy?*

Yes

If yes to hysterectomy

Partial

Complete

What is Date of hysterectomy?

Reason for hysterectomy:

excess bleeding

endometriosis

fibroid cycts

cancer

Other

If "Other", please specify

Has anyone in your family been treated for breast cancer? *

Yes

Family member diagnosed with breast cancer:

Mother

Grandmother

Sister

Daughter

What was the age of family member diagnosed?

Result of family members cancer?

Survived

Terminal

Have you ever been diagnosed with breast cancer? *

Yes

Cancer Type:

local

Lymph node involvement

Mestastatic

Left Breast

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Treatment

Surgery

Chemo

Radiation

None

If Surgery

Mastectomy

Lumpectomy

Have you ever been diagnosed with any other breast disease/? *

Yes

If yes,

Cysts/Fibrocystic

Fibro Adenoma

Mastitis/inflammatory breast disease

Have you ever had any cosmetic breast surgery or implants?*

Yes

Breast Surgery:

Silicone

Saline

Experience

Problems

No Problems

Have you ever had any biopsies or other surgeries to your breast?*

Yes

Left Breast:

Inner

Outer

Nipple

Right Breast

Inner

Outer

Nipple

Results

Negative

Positive

Calcifications

Have you ever taken contraceptive pills

Currently

Less than 5

More than 5

Have you had pharmaceutical hormone replacement therapy? HRT

Currently

Less than 5 years

More than 5 years

Do you have an annual physical examination by a doctor? *

Yes

Do you perform a montly self breast exam?*

Yes

Have you ever smoked? *

Yes

Have you ever been diagnosed with diabetes?*

Yes

Total Mammograms:

Date of last mammogram.

Were you recalled?*

Yes

Age at first mammogram:

Number of full term pregnancies:

Have you ever had breast ultrasound?*

Yes

Left Results

Negative

Positive

Right Results

Negative

Positive

Chest, Heart & Lung

Have you been diagnosed with Heart Disease?*

Yes

Have you been diagnosed with Lung Disease? *

Yes

Have you been diagnosed with Upper Spine Disorders?*

Yes

Do you suffer with upper back pain? *

Yes

Do you suffer with chest pain?*

Yes

Have you ever been diagnosed with Scoliosis?*

Yes

Have you ever had surgery to your heart?*

Yes

Have you ever had surgery to your lungs?*

Yes

Have you ever had surgery to your mid to upper back?*

Yes

Do you have asthma or shortness of breath?*

Yes

Do you currently smoke?*

Yes

Have you smoked in the past five years? *

Yes

Do you suffer with shoulder pain? *

Yes

Abdomen and Lower Back

Do you suffer with acid reflux or digestive problems? *

Yes

Do you suffer pain in the stomach? *

Yes

Do you suffer Pain below left or right breast? *

Yes

Do you suffer pain in the abdomen? *

Yes

Do you suffer pain in the lower back? *

Yes

Do you suffer pain in the lower pelvic region?*

Yes

Have you had surgery or disease in the

Stomach

Spleen(upper left)

Liver(upper right)

Kidneys

Intestines

Abdomen

Lower Back

Pelvic Region

Have you consumed alcohol in the past 24 hrs? *

Yes

Have you ever had surgery in the:

Stomach

Liver (upper right)

Intestines

Lower Back

Spleen (upper left)

Kidneys

Abdomen

Pelvic Region

Legs & Feet

Do you suffer pain in the leg?*

Yes

Do you suffer pain in the sciatica? *

Yes

Do you suffer pain in the Buttocks/Hip? *

Yes

Do you suffer pain in the knees?*

Yes

Do you suffer pain in the ankles? *

Yes

Do you suffer pain in the feet? *

Yes

Have you had surgery to the Legs? *

Yes

Have you had surgery to the Sciatica? *

Yes

Have you had surgery to the Buttocks/Hips *

Yes

Have you had surgery to the Knees? *

Yes

Have you had surgery to the ankles? *

Yes

Have you had surgery to the feet? *

Yes

Do you have any concerns or are there any details related to the information above?

Arms & Hands

Do you suffer from pain in the shoulders? *

Yes

Do you suffer from pain in the elbow? *

Yes

Do you suffer from pain in the arm? *

Yes

Do you suffer from pain in the hands? *

Yes

Have you had surgery to your shoulders? *

Yes

Have you had surgery to your arms? *

Yes

Have you had surgery to your hands? *

Yes

Have you had surgery to your elbows? *

Yes

Do you have any concerns or are there any related details to the information above?

Client

By Signing below, I certify that I have read and understand the statement above and consent to the examination. I am not an undercover agent or acting on behalf of law enforcement.

Parent or Guardian's Signature*

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