Confidential Client Information And Health History
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1CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY ~ Facial Massage
First Name: _______________________ M.I. ______ Last Name: _________________________________________________
Address: _______________________City: ______________________ State: __________ Zip: __________________________
Phone (h): ___________________ (c): ___________________ Birth Date: ______ /______ /___________________________
Email Address: __________________________________________Marital Status: ___________________________________
Male
Female
Referred by: ________________________________________________________________________
Employer: ______________________________ Occupation: ____________________________________________________
Emergency Contact: ____________________________ Phone: _______________ Relationship: _____________________
---------------------------------------------------------------------------------------------------------------------------------------------------------------
General Health Information:
Are you pregnant?
Yes____ No_____
Have/Had Skin Cancer?
Yes____ No_____
Do you have Psoriasis?
Yes____ No_____
Do you wear contacts?
Yes____ No_____
Do You have Eczema?
Yes____ No_____
Are seeing a dermatologist?
Yes____ No_____
Do you have TMJ?
Yes____ No_____
Are seeing an aesthetician?
Yes____ No_____
Are you currently using any of the following products? (Please circle)
Accutane
Antibiotics
Benzoyl Peroxide
Cortisone
Retin-A
E-mycin-T
Gylcolic Acid
Salicylic Acid
Sulfer
Vitamins
SPF
Prescription medication
What are your skin concerns? (Please circle)
Acne/Blemishes
Dull Skin
Fine Lines/Wrinkles
Dark Circles
Oily
Flakiness
Reduced Elasticity
Puffy Eyes
Large Pores
Deep Lines
Broken Capillaries
Dark Patches
Please list all food/cosmetic allergies: ____________________________________________________________________
What do you hope to accomplish from today’s facial massage? ___________________________________________
__________________________________________________________________________________________________________
Which best describes your skin?
Normal____ Combination____ Dry____ Dehydrated_____ Oily_____ Sensitive_____
Are there any other concerns/conditions not listed here that should be noted?______ If yes, Please describe:
__________________________________________________________________________________________________________
The above information is accurate and true to the best of my knowledge. I understand that the therapeutic session I
receive is provided for the basic purpose of relaxation and skin care. If I experience any pain or discomfort during a facial
massage/bodywork session, I will immediately inform the therapist. I understand that massage therapists do not diagnose
disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute for
medical attention and examination. I take full responsibility for alerting my practitioner to any physical, mental or emotional
changes that occur with my health. I also understand that cancelled or missed appointments without 24 hours notice
(medical emergencies excluded) may be charged in full for the price of the missed session.
Signature __________________________________________ Date: ___________________________
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