Client General Information Form Page 4
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4Kneaded Relief Day Spa
Client Treatment Form
Facials/Body Treatments/ Waxing /Nail Services
Name_____________________________________
Please fill out all checked sections below:
□
Facial/Body Treatment
Diet -- Check All That Apply
Yes
No
Are You Using
I take Nutritional Supplements
Alpha-Hydroxy Acids/Fruit Acids?
_____________________________
Have You Ever Had An Adverse Reaction
I take vitamin supplements daily
To A Cosmetic Product?
(Please List)__________________
If so, which product or
_____________________________
ingredient?___________________________________
I eat “junk food” often
_______________________________________________________
I smoke
_______________________________________________________
□
Facial
Do You Have Any Diagnosed Skin Conditions?
Is Your Skin Sensitive?
Yes
No
If so, describe?_____________________________
What Are You Currently Using for Your at Home
___________________________________________
Facial Care? ________________________________
What Medications Are You Using to Treat the
___________________________________________
condition(s)? ________________________________
___________________________________________
___________________________________________
___________________________________________
□
Body Treatment
What Results Would You Like to See From Your
What Products Do You Currently Use?
Service?___________________________________
Soaps
Shower/Bath Gel
__________________________________________
Body Scrub
Body Lotion/Crème
__________________________________________
Sun Protection
Self-Tanner
Do You Suffer From:
Other_________________________________
Back Problems
Dry, Flaky Scalp
Which Body Areas Are Of Concern To You?_______
Dry Skin
Dry, Damaged Hair
___________________________________________
Cellulite
Why?______________________________________
___________________________________________
□
Waxing
Is this your first hair removal treatment?
Yes
No
If no, have you ever experience bruising due to a treatment?
Yes
No
Have you undergone microdermabrasion in the past month?
Yes
No
Please indicate below the date of your most recent: Chemical Peel ___________
Waxing ________________
Please indicate whether you have any of the following conditions or if you are taking any of the following
medications:
_____ Cortisone
_____ Tetracycline
_____ Renova/Differin (in the last month)
_____ Dermal Abrasions
_____ Warts/Herpes _____ Eczema
_____ Rosacea
□
Nail Service
Have you ever worn artificial nails?__________
If yes, which type? Acrylic, Silk Wraps, Gel Caps, Fiberglass, Other_______________________________
Did you ever experience a problem with these?_____________________________________________________
If yes, explain:_______________________________________________________________________________
Do you currently have problems with your nails/skin? (Weak, Brittle, Fungus, etc)
Please explain:_______________________________________________________________________________
What improvements would you like to see with regard to your nails and hands/feet?________________________
___________________________________________________________________________________________
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Parent category: Medical