Name
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First Name
Last Name
Email
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Phone
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Currently Pasha is only accepting female adult clients and children in her practice. Please check if you have read and understand this statement.
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Chief Complaint or focus for your session:
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Please list any allergies, injuries, surgeries or health conditions (past and present) or write n/a if none.
Please indicate any conditions that you have had or currently have: (check all that apply)
What are your common areas of pain or tension?
Severity
Please list any current prescription medications or supplements you are taking, n/a if none
Do you exercise regularly?
If so, what type(s)?
Women's Health History: please check all that apply
Any notes for your therapist:
Session Selection
Please choose the elements you'd like to include in your session:
