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Return Client Intake:

Date
Month
Day
Year
Have there been any changes to your contact information? If yes, please provide details below.
Yes
No
Are you pregnant?
Yes
No
Not Applicable
Are you currently feeling ill?
Yes
No
Have you had a fever in the last 24 hours?
Yes
No
Any Current Injuries:
Yes
No
Did the injury happen in the last 36 hours?
Yes
No

Are there any significant changes in the following since your last visit?

1. Health Issues:
Yes
No
2. Allergies:
Yes
No
3. Medications:
Yes
No

Right Side - Front - Left Side

Left Side - Back - Right Side

Present Pain Level:
Stress Level:
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Massage Yogini, LLC

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