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FORMULARIO DEL CLIENTE / CUSTAIMÉIRÍ FORM

First Name

Last Name

Phone

Birthdate

Problemas de columna? / Spine problems? Y/N

Lentes de contacto? / Contact lenses? Y/N

Lumbalgia crónica? / Low back pain? Y/N

Cansancio frecuente? / Frequent tiredness? Y/N

Várices? / Varicose veins? Y/N

Migrañas? / Migraines? Y/N

Problemas cardíacos? / Heart problems? Y/N

Problemas de coagulación? / Coagulation problems? Y/N

Algo que debamos saber? / Anything we should know?

Cabeza? Head? Y/N

Extremidades superiores? / Superior limbs? Y/N

Abdomen? / Abdomen? Y/N

Planta de los pies? / Soles? Y/N

Cuello? / Neck? Y/N

Extremidades inferiores?/Lower extremities? Y/N

Espalda superior e inferior? / Upper and lower back? Y/N

Cuerpo completo? / Whole body? Y/N

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