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Blissed
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Blissed by Sol Intake Form
First name
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Last name
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Birthday
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Month
Day
Year
How did you hear about us?
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Email
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Phone
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Emergency Contact Number
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Relationship
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Please list any medications you're taking. If none, enter N/A.
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Are you currently pregnant?
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If yes, how far along? If no, enter N/A.
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Any high risk factors? If none, enter N/A.
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Do you suffer from chronic pain?
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If yes, please explain.
What makes it better?
What makes it worse?
Do you currently have any injuries?
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If yes, please explain.
Please indicate any of these conditions that apply to you:
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
Have you had a professional massage before?
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What type of massage are you seeking?
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What pressure do you prefer?
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Light
Medium
Deep
Please explain any allergies or sensitivities. If none, enter N/A.
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Please list any areas you don't want massaged. If none, enter N/A.
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Please list any areas of discomfort or tenderness. If none, enter N/A.
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Please Sign: I have completed this form to the best of my ability, and I agree to inform my therapist if any of the above information changes:
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