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Health Document

Please complete this form at least 24 hours prior to you Reflexology appointment.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Do you have allergies to any nut products?
Do you have any allegies to armatherapy?
Are you curretly pregnant? If so, let me know what trimester below.
Do you currently have any open sores on feet or hands?

Thanks for submitting!

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