Body Right Studio
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Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
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Province / State
Postal / Zip Code
Conditions
Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Other
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Massage Goals
Address Health Issues
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Strength Training
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Alternative Therapy
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Stress Relief
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Balance
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Flexibility
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Improve Fitness
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Increase Well-Being
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Injury Rehabilitation
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Positive Reinforcement
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Date of Last Massage
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Massage Frequency
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Light Pressure Preferred
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Medium Pressure Preferred
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Other
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Deep Pressure Preferred
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Allergy
Latex
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Medical
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Miscellaneous
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Environmental
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Food
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Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
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