JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
[PT_EN] ThePeonicia - Ficha-De-Consulta
* Indicates required question
Email
*
Record my email address with my response
Nome (Name)
*
Your answer
Último nome (Last name)
*
Your answer
Telemóvel (Phone number)
*
Your answer
Data de nascimento (Date of birth)
*
MM
/
DD
/
YYYY
Email
*
Your answer
Profissão (Profession)
*
Your answer
Contacto de emergência (Emergency contact)
*
Your answer
Como nos conheceu? (How did you find us?)
*
Your answer
Que tipo de massagem está a procura? (What type of massage are you seeking?)
*
Relaxamento (Relaxation)
Terapêutico (Therapeutic)
Pressão preferida (prefferred pressure)
*
Leve (Soft)
Média (Medium)
Profunda (Strong)
Indique qualquer um dos seguintes que se aplique (Please indicate any of the following that apply to you)
Tendinite (Tennis Elbow)
Artrite (Arthritis)
Fibromialgia (Fibromyalgia)
Dormência (Numbness)
Câncer (Cancer)
Diabetes
Hiper/Hipotensão (High/Low Blood Pressure)
Entorses/Entripses (Sprains or Strains)
Gravidez (Pregnancy)
Enxaqueca (Migraines)
Other:
Explique as condições que marcou acima (Explain any conditions you have marked above)
Your answer
Algum acidente ou cirurgia, há quanto(s) ano(s)? (Any injury or surgery, for how many year(s) ago?)
*
Your answer
Algum tipo de alergia à pele? (Any type of skin allergy?) E.g. lavender or rosemary oils.
*
Sim/Yes
Não/No
If your answered was "Yes". Please, mention which product ingredient..
Your answer
Está em tratamento médico? (Are you under medical treatment?)
*
Sim/Yes
Não/No
If your answered was "Yes". Please mention the treatment in question..
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
