Client General Information Form
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4Kneaded Relief Day Spa
Client General Information Form
Name
________________________________ Address____________________________
(First, M.I., Last)
City______________________________________ State__________ Zip______________________
Age____ Birth Date__________
_____
_____
Sex: M F
Height
Weight
Robe size_______ Shoe size_________
Email
_______________________________________________________________
(please print clearly)
I would like to receive email specials:
Yes □
No □
I would like to receive a monthly e-newsletter:
Yes □
No □
Telephone
___________________
___________________
____________________
(home)
(cell)
(work)
How would you prefer appointment confirmations? Phone □ (Primary phone: H C W)
Email □
Occupation _____________________________
Primary Physician_____________________________
Physician’s Phone ______________________
Referred by ______________________________ Phone
_____________________________
(if known)
Emergency Contact ______________________________ Phone _____________________________
Client Health History:
Please check any of the following conditions that may pertain to you.
The information you give will help us determine the most safe and effective treatment for you.
Please list all allergies/sensitivities you have to
Do You Have Any Health Issues?
any product or ingredient (Oils, Nuts, Iodine, etc.):
□ Blood Disorders
__________________________________________
□ Phlebitis/Blood Clot Disorder
__________________________________________
□ Anemia
Recent Injuries:
□ Heart Problems/Disease
Type and Date:_____________________________
□ High Blood Pressure (Medication:___________)
__________________________________________
□ Low Blood Pressure (Medication:___________)
Recent Surgeries:
□ Poor Circulation/Cold Hands/Feet (Circle one)
Type and Date:_____________________________
□ Numbness/Tingling/Twitches (Circle one)
__________________________________________
Where?:______________________
□ Thyroid (Circle one: Over or Under Functioning)
Current Symptoms:__________________________
□ Varicose Veins -Diagnosed by Dr?
Yes
No
__________________________________________
□ Psoriasis
__________________________________________
□ Fibromyalgia
□
□
Do you use tanning beds/sunbathe?
Yes
No
□ Arthritis/Rheumatism - Type: _____________
If Yes, How Often?_________________________
□ Cancer - Current or Remission?
□
□
Are you pregnant?
No
Yes - Due date: ______
Type: ________________
Are you taking birth control pills?
Yes
No
□ HIV/AIDS
Accutane?
Yes
No
□ Hepatitis – Type: _____________
Retin A?
Yes
No
□ Diabetes – Onset: ________
Other current medications (including topical):
Headaches - Type/Frequency: ______________
Name:____________________________________
What is your level of stress?
__________________________________________
Modest
Average
Severe
For what condition(s):______________________
Do you have any implants?
Yes
No
__________________________________________
Pacemaker, Pins in Bones, Etc.__________________
Any contagious diseases (Please List)___________
Do you wear:
Contact Lenses?
Yes
No
__________________________________________
Hearing aids?
Yes
No
__________________________________________
Dentures?
Yes
No
Is there anything else we should know about your
Have you undergone treatment from a
well-being?_________________________________
dermatologist? If so, for what conditions?________
__________________________________________
__________________________________________
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