Spa Health Intake Form
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Guest Heath Intake Form
Personal Information:
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Name___________________________________________________________________
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Phone (Home)________________________ Phone (Cell) ________________________
Address_________________________________________________________________
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City/State/Zip____________________________________________________________
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Email_______________________________________ Date of Birth________________
Occupation______________________________________________________________
Emergency Contact______________________________ Phone____________________
Date of Initial Visit________________________________________________________
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Medical History
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The following information will be used to help plan safe and effective sessions.
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Please answer the questions to the best of your knowledge.
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1. Are you currently under medical supervision? Yes No
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If yes, please explain____________________________________________________
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2. Are you currently taking any medication or using any medicated ointment, (such as
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Accutane or Retinol? Yes No
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If yes, please list_______________________________________________________
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_______________________________________________________________________
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_______________________________________________________________________
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3. Please check any condition listed below that applies to you:
( ) contagious skin condition
( ) phlebitis
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( ) open sores or wounds
( ) deep vein thrombosis/blood clots
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( ) joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
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( ) easy bruising
( ) recent accident or injury
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( ) osteoporosis
( ) recent fracture
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( ) epilepsy
( ) recent surgery
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( ) headaches/migraines
( ) artificial joint
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( ) cancer/chemo/radiation
( ) sprains/strains
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( ) diabetes
( ) fever/infections
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( ) decreased sensation/numbness ( ) swollen glands
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( ) back/neck problems
( ) allergies/sensitivity
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( ) Fibromyalgia
( ) heart condition
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( ) TMJ
( ) high or low blood pressure
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( ) carpal tunnel syndrome
( ) circulatory disorder
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( ) tennis elbow
( ) varicose veins
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( ) atherosclerosis
( ) pregnancy If yes, how far? _________
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( ) claustrophobia
( ) high blood pressure
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( ) lymphatic illness
( ) asthma
( ) stress
( ) depression
( ) cold sores
( ) nail fungus/nail discoloration
( ) warts on feet
Please explain any condition that you may have marked above_____________________
_______________________________________________________________________
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_______________________________________________________________________
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_______________________________________________________________________
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_______________________________________________________________________
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4. Is there anything else about your health history that you think would be useful for
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your therapist to know to plan a safe and effective treatment for you?
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_______________________________________________________________________
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_______________________________________________________________________
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_______________________________________________________________________
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If receiving a massage, body treatment, or facial, please complete.
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1. Do you have any allergies to oils, lotions, or ointments? Yes No
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If yes, please explain____________________________________________________
2. Do you have any allergies to latex, Lactic acid, Salicylic acid, or nuts? Yes No
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If yes, please explain____________________________________________________
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3. Do you have sensitive skin? Yes No
4. Are you wearing contact lenses ( ) dentures ( ) a hearing aid ( )?
5. Do you sit for long hours at a workstation, computer, or driving? Yes No
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If yes, please explain____________________________________________________
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6. Do you perform any repetitive movement in your work, sports, or hobby? Yes No
If yes, please explain____________________________________________________
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7. Do you experience stress in your work, family, or other aspect of your life? Yes No
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If yes, how do you think it has affect your health? muscle tension ( ) anxiety ( )
insomnia ( ) irritability ( ) other__________________________________________
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8. Is there a particular area of the body where you are experiencing tension, stiffness,
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pain or other discomfort? Yes
No
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