Takeda Day Spa
Clinic:
Takeda Day Spa
Phone:
8056591778
Address:
96 Stanislaus Ave
Ventura , California
United States 93004
Fax:
Email:
rosemarytakeda@gmail.com
Patient Information
First Name
Last Name
Email
Additional Information
Date of Birth
Gender
Contact Information
Home Phone
Work Phone
Cell Phone
Address
City
Province / State
Country
Postal / Zip Code
Emergency Contact
Name
Phone
Relationship to Patient
Patient History
Occupation
Source of Referral
Current Treatment with other Practioners
Primary Complaint
Past Treatment with other Practioners
General Health
Doctor Information
Physician's Name
Physician Address
Physician Phone
Patient Conditions
Family History
Arthritis
Cardiovascular
Respiratory
Area of Complaint
Ankles (Left)
Ankles (Right)
Arms (Left)
Arms (Right)
Elbow (Left)
Elbow (Right)
Feet (Left)
Feet (Right)
Hands (Left)
Hands (Right)
Hips (Left)
Hips (Right
Knees (Left)
Knees (Right)
Legs (Left)
Legs (Right)
Low Back (Left Side)
Low Back (Right Side)
Mid Back (Left Side)
Mid Back (Right Side)
Neck (Left Side)
Neck (Right Side)
Shoulders (Left)
Shoulders (Right)
Upper Back (Left Side)
Upper Back (Right Side)
Wrist (Left)
Wrist (Right)
Headaches
Chronic Daily Headache
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Blood
Anemia
Bleeding Disorder
Haemophilia
Hepatitis
HIV
HIV/AIDS
Hypercoagulability
Polycythemia
Thrombosis/Embolism
Cardiovascular
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Blood Clots
Cardiac Arrhythmia
Cardiovascular Accident
Cardiovascular Conditions
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Cold Feet
Cold Hands
Congenital Heart Defect
Congestive Heart Failure
Coronary Artery Disease
Heart Attack
Heart Disease
High Blood Pressure
Hyperlipidemia
Low Blood Pressure
Lymphedema
Myocardial infarction
Pacemaker
Pericarditis
Phlebitis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Varicose Veins
Emotion & Memory
Alzheimer Disease
Anxiety Disorder
Mood Disorder
Schizophrenia
Stress
Substance Use Disorder
Endocrine
Acute Pancreatitis
Diabetes
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Gastrointestinal
Celiac Disease
Constipation
Crohn's Disease
Diarrhea
Digestive Conditions
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Uncerative Colitis
Hearing
Conductive Hearing Loss
Ear Problems
Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Immune
Allergies
Anaphylaxis
Cancer
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Lupus
Non-Hodgkin Lymphoma
Rheumatoid Arthritis
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinery Tract Infection
Musculoskeletal
Amyotrophic Lateral Sclerosis (ALS)
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Bone Disease
Compartment Syndrome
Dislocation
Fibromyalgia
Fracture
Gout
Hereditary/Congenital Deformity
Jaw Pain (TMJD)
Joint Injury
Muscular Dystrophy
Myasthenia Gravis
Osgood-Schlatter Disease
Osteoarthritis
Osteomalacia
Osteoporosis
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Sinus Problems
Strain/Sprain
Neurological
Brain Disorder
Brain Injury
Burning
Cerebral Palsy
Cerebral Vascular Acciident (Stroke)
Cerebral-vascular Accident
Chronic Pain Disorder
Dizziness
Epilepsy
Herniated Disc
Huntington Disease
Loss of Sensation
Multiple Sclerosis
Numbness
Parkinsons
Seizure Disorder
Shingles
Stabbing
Stroke
Tingling
Transient Ischemic Attacks (TIA)
Vertebral and Spinal Cord Injury
Reproductive
Breast Disorder
Ectopic Pregnancy
Endometriosis
Gynaecological Conditions
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Pregnancy
Premenstrual Syndrome
Uterine Disorder
Respiratory
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Shortness of Breath
Skin
Acne
Allergic Dermatosis
Athlete's Foot
Athletes Foot
Bruise Easily
Chemical Burn
Herpes
Hypersensitive Reaction
Hypersensitive Reactions
Infectious Skin Conditions
Melanoma
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosaceea
Skin Conditions
Skin Irritations
UV Burn
Miscellaneous
Insomnia
Mental Illness
Other Diagnosed Diseases
Other Medical Conditions
Surgical Pins or Wire
Vision Loss
Vision Problems
Additional Information
Medications
Injuries
Surgeries
Subjective