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Tantra Application

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Question 1 of 15

Phone Number

Question 2 of 15

Describe why you booked this call. What do you want support with?

Question 3 of 15

How long has this been occurring?

Question 4 of 15

Any accidents or significant trauma?

A

Yes

B

No

Question 5 of 15

Please check all conditions or previous diagnoses that apply.

(Select all that apply)
A

Insomnia

B

Disturbed Sleep

C

Night Sweats

D

Sweating Easily

E

Generalized Weakness

F

Noticeable Fatigue

G

Weight Gain

H

Weight Loss

I

Edema

J

Numbness or Tingling

K

Cold Hands

L

Cold Feet

M

Generally Cold

N

Generally Hot

O

Strong Thirst

P

Lack of Appetite

Q

Excessive Hunger

R

Food Cravings

S

Tremors/Trembling

T

Dizziness/Vertigo

Question 6 of 15

Any Musculoskeletal Symptoms (Check all that apply)

(Select all that apply)
A

Musculoskeletal- Neck Pain

B

Back Pain

C

Shoulder Pain

D

Knee Pain

E

Hip Pain

F

Arthritis

G

Hand/Wrist Pain

H

Foot/Ankle Pain

I

Muscle Weakness

J

Overall Pain

Question 7 of 15

Emotional Symptoms (check all that apply)

(Select all that apply)
A

Psychological and Mental - Depression

B

Anxiety

C

Stress

D

Irritability/Frustration

E

Poor Memory

F

Lack of Concentration

G

Lack of Motivation

H

Addiction

Question 8 of 15

Any skin and hair symptoms? Check all that apply

(Select all that apply)
A

Skin and Hair-Rash

B

Eczema or Psoriasis

C

Ulcerations

D

Pimples

E

Hives

F

Dry Skin/Scalp

G

Itching

H

Hair Loss

Question 9 of 15

Any head or ENT Symptoms? (Check all that apply)

(Select all that apply)
A

Migraines/Headaches

B

Eye Pain/Strain

C

Eye Floaters/Spots

D

Poor Vision

E

Ringing/Sound in Ears

F

Poor Hearing

G

Earaches

H

Recurrent Sore Throat

I

Sinus Congestion

J

Nose Bleeds

K

Sinus/Facial Pain

L

Jaw Clicks/Pain

M

Lip/Mouth Sores

N

Dry Mouth

Question 10 of 15

Any cardiovascular problems? (Check all that apply)

(Select all that apply)
A

High Blood Pressure

B

Low Blood Pressure

C

Irregular Heartbeat

D

Chest Pain

E

Difficulty Breathing

F

Frequent Colds

G

Cough

H

Asthma

I

Sinus Infections

J

Excessive Phlegm

Question 11 of 15

Any urinary symptoms? (Check all that apply)

(Select all that apply)
A

Pain during Urination

B

Frequent Urination

C

Urgency to Urinate

D

Incogtinence/Leakage

E

Decreased Urination

F

Waking Often to Urinate

G

Kidney Stones

H

Blood in Urine

Question 12 of 15

Any Men's Health Symptoms? (Check all that apply)

(Select all that apply)
A

Genital Sores/Rash

B

Erectile Dysfuntion

C

Decreased Libido

D

Excessive Libido

Question 13 of 15

All Women's Health Symptoms? (Check all that apply)

(Select all that apply)
A

PMS

B

Painful Periods

C

Heavy Flow

D

Light Flow

E

Irregular Periods

F

Absent Periods

G

Menstrual Periods

H

Past Miscarriage

Question 14 of 15

Have you been pregnant or given birth in the past 3 years?

Question 15 of 15

Age at menopause (if applicable)

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