About You Intake Form
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Personal Info
First Name
Last Name
Contact Info
Mobile Phone
Home Phone
Email
Source of Referral
Conditions
Client Form
Do you have any allergies?
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Are you Pregnant?
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Areas of Pain or Sensitivity
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Blood Pressure Low Regular High
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Do you have Diabetes, Nerve Issues, Cancer, Circulation Issues, Large varicose veins?
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Have you had a massage before?
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Massage Focus
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Pressure Preference
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2
3
4
5
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9
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Light
Deep
Medications
Medication
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Injuries
Injury
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Surgeries
Surgery
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Other
Facial
Skin Condition-Normal, Oily, Acne, Sensitive
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What is you main concern with your skin?
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Are you/have you taken Accutane?
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Do you ever have itching/burning on your skin?
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Have you had a facial?
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