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LLerina
ByTanzzy
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First name
Last name
Email
Phone
Address
Company name
Are you taking any medications? If yes, please list: Any allergies? (oils, lotions, nuts, fruits, skin, etc.) yes no If yes, please list: Are you pregnant? Areas of broken skin?(e.g.rash,wounds) History of joint replacement surgery?
Multi choice
Areas of swelling
Autoimmune disorder
Back / neck problems
Bleeding disorders Blood clots
Bruise easily
Bursitis
Cancer
Contagious condition
Decreased sensation
Diabetes
Fibromyalgia
Seizures
Stroke
Tendinitis
Varicose veins
Vertigo / dizziness
Headaches
Heart condition
Hypertension
Kidney disease
Neurological condition
Reason for seeking massage: Relaxation Specific problem Please indicate any areas of discomfort pressure do you prefer?
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