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Contact Information
Enter your name
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Birthday
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How did you hear about Thermal Imaging Center?
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Name of person who referred you?
Specific Reason
Is there a specific reason for this exam?
Abdomen & Lower Back
Do you suffer with acid reflux or other digestive problems?
*
Yes
No
Do you suffer pain in the:
Stomach?
*
Yes
No
Below right breast?
*
Yes
No
Below left breast?
*
Yes
No
Abdomen?
*
Yes
No
Lower back?
*
Yes
No
Pelvic region?
*
Yes
No
Have you had surgery or disease in the:
Stomach?
*
Yes
No
Spleen (upper left)?
*
Yes
No
Liver (upper right)?
*
Yes
No
Kidneys?
*
Yes
No
Intestines?
*
Yes
No
Abdomen?
*
Yes
No
Lower back?
*
Yes
No
Pelvic region?
*
Yes
No
Legs & Feet
Do you suffer pain in the:
Leg?
Left
Right
Sciatica?
Left
Right
Buttocks/hip?
Left
Right
Knee?
Left
Right
Ankle?
Left
Right
Foot?
Left
Right
Have you had Surgery to:
Leg?
Left
Right
Sciatica?
Left
Right
Buttocks/hip?
Left
Right
Knee?
Left
Right
Ankle?
Left
Right
Foot?
Left
Right
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