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Patient Health History Form

Personal Info

Contact Info
Emergency Contact
Doctor

Medical Info

Insurance Info

Conditions

Energy Level
Energy
Emotion / Mood
Feet
LIV/GB (Wood)
LU/LI (Metal)
HT/SI (Fire)
KID/UB (Water)
SP/ST (Earth)
Brain Disorders
Massage Goals
Which best describes what you are experiencing
Treatment Goals
Allergy
Infectious
Genetics
Health Questions
Current Complaint
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Family History
Area of Complaint
Headaches
Cardiovascular
Musculoskeletal
Miscellaneous