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Client Intake Form
Please fill out the following form to help us understand your physical condition.
A. Patient Information
B. Emergency Information
Contact information (in case of an emergency):
C. Medications
D. Cardiovascular Health
(Please check all that apply)
E. Diabetes Mellitus Health
F. Allergies
(Please check all that apply)
Allergic to the following medications
Allergic to the following foods
G. Skin Health
Please answer if you had or have:
H. Nail Health
I. Joint/Skeletal Health
(Please check all that apply)
J. Surgeries
K. Other Diseases / Recent Injuries
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