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Client Intake & Medical History
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First name
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Last name
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Email
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Phone
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Please list any medications you are currently taking and their purpose.
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Have you ever had any heart problems? If yes, please describe.
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Have you had any surgeries? If so, please describe.
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Do you have any current injuries or painful areas in your body?
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Please describe any mental health history or psychological treatment you have had, including anxiety, stress disorders, depression, panic attacks, psychosis, etc.
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Please indicate any notable mental or medical family history:
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