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Client Intake Form

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

Massage Information

Have you had a professional massage before?
Yes
No
Do you have any issues lying on your front, back, or side?
Yes
No

MEDICAL HISTORY

Do you have or have you had any of the following conditions? If yes, please select them:

if yes, please select them:
Select all that apply
Select all that apply
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