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Online Intake Form

Client Information

Please complete the Health History as accurately as possible. These forms will help to ensure that you receive a safe and effective treatment. If at any time your health status changes, please let us know as soon as possible prior to your next treatment so that we may adjust accordingly. All information is strictly confidential and cannot be released to anyone without your written consent. If at any time you have any questions, feel free to contact us at withinbodywork@hotmail.com.

Birthday
Year
Month
Day

Health History

Please check all that may apply. The Health History form is more in-depth to encompass both Manual Osteopathy & Massage Therapy so that the therapist may appropriately make recommendations and treatment suggestions.

General Health
General Stress Levels
Allergies
Muscle/Joints
Skin
Cardiovascular Health
Respiratory Health
Digestive Health
Other
Previous Health Care
Date
Year
Month
Day
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