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Lothian Massage & Acupuncture
Lothian Massage & Acupuncture
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Pre-assessment Form
Please provide information
Name *
Email address
Message *
1. What would you like help with? *
Head / headache
Face / jaw
Neck
Shoulder
Upper back
Lower back
Hip
Elbow
Wrist / hand
Chest / ribs
Knee
Ankle
Foot
Other *
2. When did it start? *
Less than 1 week ago
1–4 weeks ago
1–3 months ago
3–6 months ago
More than 6 months ago
Long-term / recurring problem
3. Pain / discomfort right now? 0 = No pain | 10 = Worst pain imaginable *
4. About your symptoms *
Aching
Sharp
Burning
Tingling
Numbness
Stiffness
Throbbing
Heavy / tight
Other
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