Contact Information

Enter your name *

Phone *

Enter your email address *

Address *

Enter your home address

Birthday *

Select the month of your birthdate

*

Type the day of your birthdate

*

Type the year of your birthdate

How did you hear about Thermal Imaging Center? *

Name of person who referred you?

Specific Reason

Is there a specific reason for this exam?

Head & Neck

Do you suffer with headaches? *

Yes

No

How many per month?

Do you have known allergies? *

Yes

No

What type?

Food

Environmental

Do you have TMJ or does your jaw click? *

Yes

No

Do you currently have a cold? *

Yes

No

Are you being treated for a thyroid disorder? *

Yes

No

Type?

Do you have neck pain? *

Yes

No

Do you suffer with upper back pain? *

Yes

No

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

Yes

No

Do you have a family history of stroke? *

Yes

No

Do you currently suffer with sinus problems? *

Yes

No

Do you have history of dental problems? *

Yes

No

Type?

Root canal

Gum disease

Implant

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

Yes

No

Have you ever been diagnosed with high cholesterol? *

Yes

No

Chest, Heart & Lungs

Have you been diagnosed with:

Heart disease? *

Yes

No

Lung disease? *

Yes

No

Upper spine disorders? *

Yes

No

Do you suffer with chest pain? *

Yes

No

Have you ever had surgery to your:

Heart? *

Yes

No

Lungs? *

Yes

No

Mid to upper back? *

Yes

No

Do you have asthma or shortness of breath? *

Yes

No

Do you currently smoke? *

Yes

No

Have you smoked in the past 5 years? *

Yes

No

Have you consumed alcohol in the past 24 hours? *

Yes

No

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

Arms & Hands

Do you suffer with pain in the:

Shoulder?

Left

Right

Elbow?

Left

Right

Arm?

Left

Right

Hand?

Left

Right

Have you had surgery to:

Shoulder?

Left

Right

Elbow?

Left

Right

Arm?

Left

Right

Hand?

Left

Right