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Phoenix Therapy Galway Intake Form

I am
New client
Returning client
Date of birth
Day
Month
Year
Have you had a professional massage before?
Yes
No
If yes, date of last treatment
Day
Month
Year
I confirm that there have been no changes to my health since my last visit.
Return to a health questionnaire.
How would you rate your general health?
Excellent
Good
Fair
Poor
Are you receiving any of the following

Do you suffer from?

HEAD/NECK
RESPIRATORY
NERVOUS SYSTEM
MUSCULOSKELETAL SYSTEM
REPRODUCTIVE
CARDIOVASCULAR
SKIN & INFECTIONS
OTHER CONDITIONS
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