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Were you referred? Text? Yes No Age: Sex: What depth of pressure do you prefer? Light Male Female Medium Firm Phone: In case of emergency, contact: If you answer yes to any of the following questions, please explain as clearly as possible. Yes No Do you have diabetes? If Yes, are you insulin dependent? Yes No Is your insulin Well Managed? Yes No Yes No Do you have allergies (ie: almond/nut, apricot/fruit, etc) Yes No Do you experience frequent headaches?.

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