The Body Shop & Massage Day Spa
|
|
Date *
|
MM
|
/
|
DD
|
/
|
YYYY
|
|
|
Name *
|
|
|
|
Address *
|
|
|
|
Home Phone *
|
|
|
|
Cell Phone
|
|
|
|
Business Phone
|
|
|
|
Email *
|
|
|
|
Confirm Email *
|
|
|
|
Emergency Contact *
|
|
|
|
Emergency Contact Phone Number *
|
|
|
|
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
|
|
|
