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Rooted
respite & reflexology
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Client Intake
Name
Phone
Email
Birthday
Month
Day
Year
Address
Preferences
Eye covering
Yes
No
Steamed towels
Yes
No
Heated table
Yes
No
Aromatherapy
Yes
No
OK with eucalyptus
Yes
No
Health and wellness history
Do you have any conditions that I should be aware of? Have you suffered any injuries?
Do you have any conditions affecting your hands or feet?
Are you pregnant? If so, when are you due?
Do you have any specific hopes or intentions for today's session?
Please mark any areas where you are experiencing tenderness, pain, or other difficulty.
Head
Face/sinus
Neck
Shoulder/s
Arm/s
Hand/s
Chest/breast
Abdomen
Upper back
Mid back
Lower back
Hips
Leg/s
Knee/s
Ankle/s
Foot/feet
Digestive system
Respiratory system
Lymphatic system
Immune system
Reproductive system
Is there anything else you'd like me to be aware of?
Submit
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