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Personal Information
Name
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First
Last
Email
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Occupation
Medical Information
Information Information Please
Are There Any Allergies or Medical Information We Should Be Aware Of?
No
Yes
Please Detail Any Allergies or Medical Information We Should Be Aware Of
Are You Currently Pregnant?
No
Yes
How Far Along?
Are You Currently Under Care of a Physcian/Chiropractor?
No
Yes
Please Detail The Reason
Are There Any Current or Previous Injuries or Surgeries That We Should Be Aware Of?
No
Yes
Please Detail Any Current or Previous Injuries or Surgeries
Are There Any Current Areas Of Pain, Tension, or Discomfort (E.g. Arm, Leg, Neck, Etc.)
No
Yes
Please Detail Any Current Pain, Tension, or Discomfort Areas (E.g. arm, leg, neck, etc.)
Massage Information
Have Have You Had a Professional Massage Before?
Yes
No
What Type Of Massage Are You Seeking?
Relaxation
Therapeutic
What Pressure Do You Prefer?
Light
Medium
Firm
Are There Any Areas (Feet, Face, Abdomen, etc.) You Do NOT Want Massaged?
Yes
No
If yes, please indicate where?
Client Signature
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