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Only for Massage Patient
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How did you hear about us?
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Please check mark the below medical conditions
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Diabetes
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High Blood Pressure
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Kidney Issues
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Cardiac
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Circulatory
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Arthritis
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Joint Dislocation
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Joint Swelling
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Broken Bones (Within 2 years)
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Recent Surgery
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Numbness
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Stabbing Pain
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Irritable Bowel Syndrome
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Bruise Easily
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Seizures
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Pregnant
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Wear Contacts or Dentures
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Major Allergies
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Pain or stiffness in the Neck or Back
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Pacemaker
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Arm or Leg Pain
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Something not listed?
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Have you had a massage before?
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If Yes, When?
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How was the result with the massage?
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Good
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Bad
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Not Applicable
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How have your results been with medical visit to
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Physiatrist
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Good
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Bad
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Not Applicable
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Chiropractor
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Good
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Bad
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Not Applicable
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Physical Therapy
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Good
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Bad
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Not Applicable
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Are your symptoms getting worse with time?
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How bad are your symptoms on a scale of 1-10
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Did you know that massage therapy is covered by
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health insurance plans within medical facilities
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Would you like us to check your health insurance
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benefits for medical/massage/therapy benefits
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Declaration (Read only) - Do not click on use photo
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Declaration
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