Miami Spa, Salon, Studio & Cafe | Bringing beauty to South Miami for 30 years » Health Survey
Your Email Address:
Your Phone Number:
Do you have any of the following risk factors?
Smoker Diabetes Hypertension High Cholesterol None of the Above
Check any of the following that apply:
Headaches Dizziness Neck Pain Arm or Hand Pain Numbness and/or Tingling in Extremities Pain Between Shoulders Lower Back Pain Painful and stiff joints Pain Radiating Down Legs Fatigue Hormonal Problems Fertility Issues Sleep Problems Anxiety or Depression Sinus/Allergies Gynecological Issues None of the Above
Any Additional Questions or Comments on the Above Risk Factors or Conditions?
After this evaluation, I have agreed to be contacted by Dr. Ruth Lacayo L.,Ap and possibly set up an appointment for treatment.
Electronic Signature (Type Your Full Name):