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Polarity Therapy Intake Form Name Phone h b Address City State Zip Email Birthdate Physician Phys Phone Emergency Contact Phone Number How were you referred here Are you receiving/Have you received any other form of therapy. Please check all that apply. Counseling Massage Therapy Other Form of Bodywork Chiropractic Acupuncture/Chinese Med Nutrition/Homeopathy Physical Therapy Other Please explain why you are seeking an Energy Bodywork Session Please include any physical emotional or mental symptoms that are currently present. Use the back of this page if necessary Please list any major illness injury you have had* List any medications vitamins or herbs you are currently taking. Please check all that apply. Counseling Massage Therapy Other Form of Bodywork Chiropractic Acupuncture/Chinese Med Nutrition/Homeopathy Physical Therapy Other Please explain why you are seeking an Energy Bodywork Session Please include any physical emotional or mental symptoms that are currently present. Use the back of this page if necessary Please list any major illness injury you have had* List any medications vitamins or herbs you are currently taking.

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Keywords relevant to Polarity Therapy Pdf

  • bodywork
  • Polarity
  • Acupuncture
  • Nutrition
  • INTAKE
  • medications
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