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Get Pauline Vanstone Health History Form for Registered Massage Therapy

_____ Pregnant Due Date ___________ MUSCLE / JOINT â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ Muscle Strain Ligament Sprain Tendonitis Bursitis Arthritis Osteoporosis Herniated Disc Scoliosis Dislocation Location_____ Fracture Location _______ OTHER CONDITIONS â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ Diabetes Type I Type II Allergies ___________ Cancer Type_________ Fibromyalgia Multiple Sclerosis Epilepsy Motor Vehicle Accident Date: _____________ OTHER HEALTH CARE â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ Chiropract.

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