The Body Shop & Massage Day Spa

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Name *

First

Last
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone *

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Cell Phone

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Business Phone

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Email *
Confirm Email *
Emergency Contact *

First

Last
Emergency Contact Phone Number *

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How did you hear about us?
Occupation
Do you exercise regularly?
 No 
 Yes 
Are you sensitive to touch in areas?
 No 
 Yes 
Do you have any numbness/stabbing pain?
 No 
 Yes 
Are you currently on the HCG protocol?
 No 
 Yes 
Are you pregnant?
 No 
 Yes 
Are you under physician/dermatologist care?
 No 
 Yes 
Have you had any surgeries in the last 9 months?
 No 
 Yes 
If yes, please specify
Please list any other health conditions
Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc.
Areas of Pain/Tension
 None 
 Neck 
 Head 
 Shoulders 
 Arms 
 Back 
 Legs 
 Feet 
 Hands 
Health Conditions *
 None of the Below 
 Diabetes 
 Cardio 
 High Blood Pressure 
 Injuries 
 Circulatory 
 Seizures 
 Broken Bone 
 Cancer 
Do you smoke?
 No 
 Yes 
Do you wear contact lenses?
 No 
 Yes 
Do you ever experience skin breakouts?
 No 
 Yes 
Do you ever experience lily shine during the day?
 No 
 Yes 
Do you experience burning, itching sensations on your skin? *
 No 
 Yes 
Do you drink more than 4 caffeinated drinks per day?
 No 
 Yes 
Do you experience ingrown hairs?
 No 
 Yes 
Do you experience irritation from shaving?
 No 
 Yes 
Do you sunbathe or use tanning beds?
 No 
 Yes 
Do you burn easily in moderate sunlight?
 No 
 Yes 
Do you blush easily when nervous?
 No 
 Yes 
Do you have a tendency to redness?
 No 
 Yes 
Do you suffer from sinus problems?
 No 
 Yes 
Do you experience flaky or tightness on your skin?
 No 
 Yes 
Do you experience allergic reactions to cosmetics, medicine, iodine, pollen, food, animals, fragrance, hydroxyl acids, sunscreens *
 No 
 Yes 
Do you have any special skin problems? *
 No 
 Yes 
If yes, please specify
Do you have any special skin problems? *
 No 
 Yes 
If yes, how long ago
Are you currently on any products that contain the following ingredients: Glycolic acid/Lactic acid, Exfoliating scrubs or Hydroxy acids, Vitamin A derivatives? *
 No 
 Yes 
How much water do you consume daily?
How many alcoholic beverages do you consume weekly?
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
What prescription skin products do you use? (ex: Accutane, Retin A, Renova, Adapalene)
What is your skin care goal?

The Body Shop Massage & Day Spa is a Non-Partnership Association with Skin Care, or Contractor Therapist

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