Spa Health Intake Form (Page 2 of 2) in pdf

If receiving a massage, please complete.

Have you had a professional massage before? Yes No If yes, how often do

you receive massage therapy?

_______________________________________________

2. Do you see a chiropractor? Yes No If yes, how often? ___________________

3. Do you have any difficulty lying on your front, back, or sides? Yes No

____

If yes, please explain________________________________________________

4. Do you have any particular goals in mind for this massage session? Yes No

___

If yes, please explain________________________________________________

____

Circle any specific areas you would like the massage therapist to concentrate on

___

during the session:

___

( ) Head

( ) Neck

( ) Shoulders

( ) Upper arms

( ) Forearms

( ) Hands

( ) Upper back

( ) Lower back

___

( ) Hips

( ) Thighs

( ) Lower Legs ( ) Feet

___

____

If receiving an Age Defying Lift or Ultra Red Carpet Facial, please complete.

Are you pregnant? Yes No

Do you have any metal implants in the head or neck? Yes No

Do you have any silicone implants in the head or neck? Yes No

Do you have a pacemaker? Yes No

Do you have epilepsy? Yes No

Have you undergone any cancer treatments in the last 5 years? Yes No

___

Do you have Thrombosis or Phlebitis? Yes No

Do you have any heart or muscular conditions? Yes No

Have you used Retin A in the last 4 weeks? Yes No

Have you used Accutane in the last 6 months? Yes No

___

Have you had any collagen or injectable filler in the last 2 months? Yes No

___

Have you had Botox in the last 4 weeks? Yes No

___

If receiving a Waxing Treatment, please complete.

Wax Temp:_________ (Range should be between 150º-160º —Staff use only)

Are you currently being treated for any type of cancer? _______________________

Are you currently being treated for diabetes? _______________________________

Have you used any Glycolic or Alpha Hydroxy Acids in the past 72 hours? _______

Are you currently using Retin A products? _________________________________

Have you recently received a chemical peel? ________________________________

Have you used Accutane in the past 6 months? ______________________________

Have you used Renova recently? _________________________________________

Are you exposed to the sun on a daily basis? ________________________________

Do you work near a UV source? _________________________________________

Do you regularly use tanning beds? _______________________________________

Are you currently taking any medications, being treated by a dermatologist or plastic

surgeon for any conditions or surgery? ________Please explain? _______________

____________________________________________________________________

Start of last menstrual cycle:

___

________________________________________________

(Be aware that your skin will be extra sensitive during this time.)

___

I, ________________________________________________________ (print name)

___

understand that the treatment I receive is provided for the basic purpose of relaxation

___

and stress relief. If I experience any pain or discomfort during this session, I will

___

immediately inform the therapist so that the pressure and/or strokes may be adjusted

to my level of comfort. I further understand that treatment should not be construed as

a substitute for medical examination, or diagnosis, and that I should see a physician,

chiropractor or other qualified medical specialist for any mental or physical ailment

___

that I am aware of. I understand that the therapists are not qualified to perform spinal

___

or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness,

___

and that nothing said in the course of the session given should be construed as such.

Because treatment should not be performed under certain medical conditions, I af-

firm that I have stated all my known medical conditions, and answered all questions

honestly. I agree to keep the therapist updated as to any changes in my medical pro-

file and understand that there shall be no liability on the therapist’s part should I fail

to do so.

___

Signature of Guest_____________________________________________________

___

Date ____________________________

Signature of Therapist__________________________________________

___

Date_____________________________

___

Signature of Therapist__________________________________________

Date_____________________________

___

Signature of Therapist__________________________________________

Date_____________________________

Spa Health Intake Form Page 2

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