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| | If you have any feedback on how we can make our new website better please do contact us. We would like to hear from you. | |
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Please bring print and fill out this form and bring it with you to your appointment
Yoga Plus Shiasu Massage form
Personal Shiatsu Health Record
705-294-1228 or 905-251-0129
www.yogaplusmore.com
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Name |
Date |
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Date of birth |
Age |
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Marital status |
Education |
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Profession |
Hours worked/day |
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Occ. hazards |
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address |
City |
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Email address |
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Tel (work) |
Tel (Home) |
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Medical History |
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Recent checkup |
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Operations |
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Traumas |
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Sports |
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Hobbies |
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Relaxation |
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Are you currently on medication? |
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Are you under stress? |
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Are you pregnant |
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Do you have any muscle pain and if yes please specify |
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Do you have any bone problems and if yes please specify |
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Doctors name |
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Doctors phone number |
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Doctors address |
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In case of emergency please provide us with a name and phone number of whom we could contact
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How did you hear about us? |
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