Shiatsu info form
I look forward to seeing you and treating you with Shiatsu. Please fill out this form so that I have a better idea of your specific health state, and how I can treat you. Namaste.
Email address *
Full Name *
Your answer
Phone Number
Your answer
Date of birth
MM
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DD
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YYYY
Heart / Small Intestine - Do you have ongoing issues with:
Stomach / Spleen - Do you have ongoing issues with:
Lung / Large Intestine - Do you have ongoing issues with:
Kidney / Bladder - Do you have ongoing issues with:
Liver / Gall Bladder - Do you have ongoing issues with:
General Health Questions
If you would like to add more details about anything checked above, please do so here:
Your answer
Are there any areas that would like special attention?
Your answer
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