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Email address
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Client Name:
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How did you hear about me? (referral, Facebook, etc.)
Have you had a massage/bodywork before?
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Types of massage/bodywork received:
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Reasons for seeking massage? (relaxation, injury, etc.)
Description of injury/health condition:
Possible complications/medications:
Expected outcomes (functional improvement, symptom relief, wellness):
Typical activities of daily living (affected by condition?):
Occupation (affected by condition?):
Do you have special needs I should prepare for:
Do you have any questions or concerns:
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