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Medical Questionnaire
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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Studio Sante - ankieta dotycząca zdrowia
1
Do you have any current health conditions?
Specify if you have any health conditions.
Yes
No
2
Rate your overall health condition:
Rate your health condition on a scale of 1 to 10.
3
Are you currently taking any medications?
Specify if you are taking any medications.
Yes
No
4
Do you have any allergies?
Specify if you have any allergies.
Yes
No
5
Do you have any open wounds or cuts?
Specify if you have any open wounds or cuts.
Yes
No
6
Have you had any recent surgeries?
Specify if you have had any recent surgeries.
Yes
No
7
Do you experience chronic pain?
Specify if you experience chronic pain.
Yes
No
8
Are you pregnant?
Specify if you are currently pregnant.
Yes
No
9
Please list any specific contraindications to massage:
List any conditions or factors that would make massage therapy unsafe or unsuitable for you.
10
Additional comments or information:
Provide any additional information relevant to the patient's health condition and contraindications to massage.
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