Highest Potential Massage Intake

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Personal Info
Contact Info
Emergency Contact
Other
Medical Info
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Conditions
Energy
Well Being
HT/SI (Fire)
LIV/GB (Wood)
Treatment Goals
Emotion / Memory
Feet
LU/LI (Metal)
SP/ST (Earth)
Oncology
Area of Complaint
Headaches
Musculoskeletal
Blood
Cardiovascular
Skin
Immune
Family History
Kidney
Miscellaneous
Prenatal (check boxes to enter details below)
Massage Goals
Which best describes what you are experiencing
Allergy
Emotion / Mood