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Contact lenses *
 YesNo
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Allergies *
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Diabetes *
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Cardiac or circulatory problems *
 YesNo
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High blood pressure *
 YesNo
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Joint swelling *
 YesNo
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Arthritis *
 YesNo
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Osteoporosis *
 YesNo
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Varicose veins *
 YesNo
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Contagious infections or diseases *
 YesNo
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Recent broken bones *
 YesNo
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Recent accidents or injuries *
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Recent surgeries *
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Frequent stress *
 YesNo
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Back pain *
 YesNo
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Neck pain *
 YesNo
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Frequent headaches *
 YesNo
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Numbness, tingling or sharp pains *
 YesNo
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Sensitivity to touch or pressure *
 YesNo
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Do you bruise easily? *
 YesNo
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Are you pregnant? *
 YesNo
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Are you taking medications? *
 YesNo
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I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or technique may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I also agree to give 24 hours’ notice to change or cancel an appointment, and that no-shows will be charged full session price.

Please type your full name below to agree with the above statement. *
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