WPC MzrIPR-]ma%78Ma ܍2T+D`,֭9r<9*|5) ݡڏb؊ \w2O*H1{ tf呲?g^ 6~a[gD֭5ܨm?*+"o o¸qSx ?iʤǁ f/5u].xn꺱 ɑ̛  e Xqsyۍ~^^y'«|Alwiy_2&8\s ߪ&$l@5A_hnhҷLxdwRe|סWW$bW#!_L.Guk֥&hkc(y'QyfۻKc9J,n66SArax0MrRTO/$^Z=@.VPཌྷ#UNQ % 0:U6^  0c! 1u 72 0w+ 0 0, 0 0 0G 0" 0D 1U 72w4 - m/ 1F 72NEPSON Stylus CX8400 Series0(  Z6Times New Roman RegularX($USUS.,(ZAllegro BT #@ (;3$2#  0  .3  0  3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)(O;$0  2#  a  .3  0` (#(#(b$0  0` (#(#2#   .3  0 ` (#` (#(xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(#  x"CW[_cgkosCheck BoxCheck Box&&&&&&&&&P?3|xU xRGaeimquy}Oh My StarsStar BulletsHHHHHHHHH !USUS.,  _XXXXRkQXX  BlossomingSoulMassage,LLC  #XXQRk\#?XXClientIntakeForm J {  Name___________________________________DateofBirth___________ > Address_______________________________________________________  A Home_Phone_____________ԀWork____________CellPhone____________   EMail_____________________Referredby_________________________ W   EmergencyContact_________________YourOccupation________________  Z  #XX?# XXHealthInfo#XX D#qXX   Pleasecheckthefollowingconditionsthatyouarecurrentlyexperiencingorhave   experiencedinthepas>t:#Ctq=##XXCt# )y   ("y3"3"  XXXX(X(#(#(3<2"&3  0    Headaches/Migraines3<݌(x Ќ  "3"  3L2"&3  0    JointPain3Ly݌^ Ќ  "3"  3 2"&3  0    VaricoseVeins3 9݌D Ќ  "3"  32"&3  0    RespiratoryProblems3݌* Ќ  "3"  32"&3  0    CarpelTunnelSyndrome3݌ Ќ  "3"  3f 2"&3  0    Diabetes3f ݌ Ќ  "3"  3$ 2"&3  0    Epilepsy3$ Q ݌ Ќ  "3"  3 2"&3  0    HighBloodPressure3  ݌r Ќ  "3"  3 2"&3  0    LowBloodPressure3 ݌X Ќ  "3 "  3s 2"&3  0    HeartCondition3s ݌> Ќ  "3 "  38 2"&3  0    BloodClots38 e ݌$t Ќ  "3 "  3 2"&3  0    _Scoliosis_3 &݌ Z Ќ  "3 "  32"&3  0    SkinConditions3݌ @ Ќ  "3 "  32"&3  0    _TMJ_3݌!&  Ќ  "3"  3v2"&3  0    LowBack/HipPain3v݌" ! Ќ  "3"  3>2"&3  0    CirculatoryProblems3>k݌#" Ќ  "3"  32"&3  0    NeurologicalProblems35݌$# Ќ  "3"  32"&3  0    DigestiveProblems3݌n% $ Ќ  "3"  32"&3  0    TBorothercommunicablediseases3݌T&!% Ќ  "3"  3r2"&3  0    Surgeries3r݌:'"& Ќ  "3"  312"&3  0    Numbness/Tingling31^݌ (p#' Ќ  "3"  32"&3  0    Dizziness/FaintingSpells3%݌)V$( Ќ   *"&* "3"  32"&3  0 p   Dislocations/Sprains3 ݌(x*p(#p(# Ќ  "3"  32"&3  0 p   PressureSores3݌^+p(#p(# Ќ  "3"  3k2"&3  0 p   Neck/ShoulderPain3k݌D,p(#p(# Ќ  "3"  332"&3  0 p   _Fibromyalgia_33`݌*-p(#p(# Ќ  "3"  32"&3  0 p   Cancer3B݌.p(#p(# Ќ  "3"  32"&3  0 p   Arthritis3݌/p(#p(# Ќ  "3"  32"&3  0 p   Stroke3݌0p(#p(# Ќ  "3"  3L2"&3  0 p   ChronicPain3Ly݌r1p(#p(# Ќ  "3"  32"&3  0 p   Paralysis3;݌X2p(#p(# Ќ  "3"  32"&3  0 p   MultipleSclerosis3݌>3p(#p(# Ќ  "3 "  32"&3  0 p   SinusProblems3݌$t4p(#p(# Ќ  "3!"  3Y2"&3  0 p   FracturesorBoneTrauma3Y݌ Z5p(#p(# Ќ  "3""  3' 2"&3  0 p   MuscleCramping3' T ݌ @6p(#p(# Ќ  "3#"  3 2"&3  0 p   Herpes/Shingles3 !݌!&7p(#p(# Ќ  "3$"  3!2"&3  0 p   SleepDisorders3!!݌" 8p(#p(# Ќ  "3%"  3w"2"&3  0 p   AthletesFoot3w""݌#9p(#p(# Ќ  "3&"  3:#2"&3  0 p   CarAccidents3:#g#݌$:p(#p(# Ќ  "3'"  3#2"&3  0 p   HerniatedDiscs3#*$݌n% ;p(#p(# Ќ  "3("  3$2"&3  0 p   Ulcers3$$݌T&!<p(#p(# Ќ  "3)"  3~%2"&3  0 p   Osteoporosis3~%%݌:'"=p(#p(# Ќ  "3*"  3@&2"&3  0 p   AreyouWearingContactLenses?3@&m&݌ (p#>p(#p(# Ќ  "3+"  3'2"&3  0 p   AreyouPregnant?3'B'݌)V$?p(#p(# Ќ   p      *"&A (X(qXXPleaseExplain_______________________________________________________ ,'A ___________________________________________________________________ -)B _ԇHaveyoueverhadaprofessionalmassagebefore?___________________________  Reasonforvisit______________________________________________________ K Doyouhaveanyothermedicalconditionsyourtherapistshouldbeawareof?_____ 6 ___________________________________________________________________   Pleaselistanymedicationsyouarecurrentlytaking_________________________  l ___________________________________________________________________    Pleaselistanyallergies/sensitivities______________________________________ R  ___________________________________________________________________ =   qq HowdidyouhearaboutBlossomingSoulMassage?___________________________   Pleasereadthefollowinginformedconsentandpoliciesstatementbeforesigning: #s ! ,!  (Ryy, # q@,#XX "3"  3.2RH3  0    # XX-#& % XX %& Iunderstandthatmassagetherapyandbodyworkareintendedtoreducepaincausedbu  muscletensionandspasm,increaserangeofmotion,enhancerelaxationandimprove  circulationandenergyflow.3.I.݌(#(# Ќ  -"3"  -3502RH3  0    Iunderstandthatthetherapistdoesnotdiagnoseillness,diseaseoranyotherphysicalor p mentaldisorder.Thetherapistdoesnotprescribemedicaltreatmentorpharmaceuticals350x0݌V(#(# Ќ  "3"  312RH3  0    Iunderstandthatitmaybenecessarytoobtainadoctorsreleasebeforebeginningtherapy.311݌<(#(# Ќ  "3"  322RH3  0    Iunderstandthatmassagetherapyisnotasubstituteformedicalexaminationandthatitis "r recommendedthatIseeamedicalpractitionerorotherhealthcarespecialist.32 3݌X(#(# Ќ  "3"  3P42RH3  0    Ihaveinformedthetherapistofallofmyknownmedicalandphysicalconditionsandagree > toupdatethemassagetherapistofanychanges.Thetherapistshallnotbeliable,shouldI $ forgettodoso.3P4}4݌ (#(# Ќ  "3"  352RH3  0    Iagreetoactivelyparticipateinthesession,withregardstopainlevels,discomfortandany  othertypesofsensations,sothetreatmentcanbeadjustedaccordingly.35"6݌ (#(# Ќ  "3"  3g72RH3  0    Iunderstandthatanyillicitorsexuallysuggestivebehavior,remarksoradvancesmadeby l ! mewillresultinimmediateterminationofthesession.3g77݌R!"(#(# Ќ  b0! !  (Ryy "3"  3{92RH3  0    Iunderstandthatitismyresponsibilitytogive24hoursnoticewhenIneedtocancela 8"# massageappointmentsothatthetherapisthastimetofillmytimeslotwithanotherclient.3{99݌#n$(#(# Ќ  "3"  3 ;2RH3  0    Bysigningthisrelease,Ihearbywaiveandreleasethetherapistfromanyliability,past, $T% presentandfuture,relatingtomassagetherapy.3 ;:;݌$: &(#(# Ќ  #& %XX.#O  %& Ihavereadthepolicystatementandagreetothepoliciestherin. &!( eSignature:______________________________________Date:____________________ (#* Ѐ