Services History Form | Heavenly healing/Dr. Z Meta

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Services History Form

Contact Us

Name:

Email:

Phone:

Work Phone:

Street Address:

City:

State:

Zip Code:

Birth Date:

Age:

Occupation:

Height/Weight:

Primary MD

Alternative Care:

Have you ever received a professional massage?

If yes, frequency?

When was your last treatment?

Do you have a history of the following?

Headaches

Neck Pains

Shoulder/Arm Pain

Mid-back Pain

Low-back Pain

Abdominal Pain

Hip/Leg Pain

Spasms/Cramps

Numbness/Tingling

Joint Ache

Sprains

Seizures

High Blood Pressure

Heart Attack

Stroke

Varicose Veins

Blood Clots

Breathing Difficulty

Less Range of Motion

Jaw Pain/TMJ

Fibromyalgia

Diabetes

Nervous Tension

Allergies to Oils

Wear Contacts

Cancer

Arthritis/Bursitis

Pregnacy

Do you have any of the following recently?

Headache

Inflammation

Severe Pain

Sunburn

Irritated Skin Rash

Poison Ivy

Open Cuts

Bruises

Burns

Cold/Flu

Nausea

Any other conditions to be aware of?

Medications currently taking? For what reason?

Please check the areas the you DO NOT GIVE PERMISSION to receive massage:

Back

Chest

Legs

Neck

Buttocks

Head

Arms

Face

Adomen

Feet

What results do you want from your massage?

Please indicate consumption of following.(1 None, 2 Light, 3 Moderate, 4 Heavy)

Salt

Sugar

Caffeine

Tobacco

Alcohol

Exercise

Water

Thank you for contacting us.
We will get back to you as soon as possible.

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My goal is to enable you to live a pain-free life, with happniess.

SERVICES

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Intuitive Counsel

General Health

Spiritual/Mental Health

Bodywork/Reiki

Crystal Matt Therapy

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HOME
SERVICES
ABOUT
- CONTACT US
NONPROFIT
PRODUCTS
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CONTACT

(910)-600-4419

Drz@drzmeta.com

219 Gores Row

Wilmington, NC. 28401

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