HEALTH INFORMATION & HISTORY Patient’s Name __________________________________________________ Date_ ______________________________ Address____________________________________City_ _________________ State__________ Zip__________________Occupation_ _______________________________SSN_#_ _______________ Date_of_Birth_ ______________________Height_______ Weight________ Single______ _Ma
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Microsoft word - client profile card jan 14.docCLIENT PROFILE CARD
Today’s Date: ___________________Date of Birth _____/_______/____________
Bus Ph: ( ) _________________________ Res Ph: ( ) ___________________________________
Cell Ph: ( )________________________________Cell Provider:_____________________________
Emergency Contact:______________________________________Phone ________________________
Referred by:___________________________________ Have you ever had a massage? Yes___ No___
Facial? Yes___No___ PhotoRejuvenation? Yes___No___ Microdermabrasion? Yes___No_______
What is your specific concern about your skin?______________________________________________
How long have you noticed your condition?_________________________________________________
Medical: Are you currently or within the last year under any Doctor’s care? Yes____ No _________
Circle any Health Problems: Diabetes, Thyroid, Heart, Cancer, High or Low Blood Pressure,
HIV/Aids, Epilepsy, Arthritis, Tendenitis, Bursitis, Nail or Foot Fungus, Urinary or Kidney
Problems, Varicose Veins, Hepatis A, B, or C, Circulatory Problems, Depression, Lupus, Pacemaker,
Psoriasis, Scleroderma, Fever Blisters, Eczema, Stroke, Sunburn, Anemia, Fibromyalgia, Stress
related illness, Scoliosis, Chemotherapy, Radiation, Skin Disease, Hormone Problems, Cold hands or
feet, Contact Lens, Blood Disorder, Blood Thinner, Artificial Implants, Phlebitis, Hyper/Hypo
Pigmentation, Claustrophobia, Sinus, Headaches, Contagious Diseases, Joint Swelling, Skin Cancer,
Hysterectomy, Alcoholism, Whiplash, Other_______________________________________________
Are/have you using/taking: Antibiotics, Accutane, Retin A, Glycolic or Alphahydroxy acids, Azelex,
Differin, Tazarac, Tanning Bed, Diet Tablets, Smoke, Stimulants, Oral Contraceptives, Laxatives,
Diuretics, Other ______________________If so, How long?___________________________________
Medications, & Vitamins – List all and why: ________________________________________________
If you have known allergies, please list them:________________________________________________
Are you allergic to any beauty products that you know of? Yes___ No ___, If so, please let us know
what they are ________________________________________________________________________
Are you allergic to: Aspirin, Glycolic, Any plants, botanicals, Nuts. If yes, please provide their
Have you undergone surgery recently? Yes____ No____Explain______________________________
________________________________Any Numbness/Stabbing pain anywhere: _________________
Have you had recent plastic surgery? Yes ____ No ____Explain ______________________________
If you recently had surgery, do you have permission from your doctor for a facial ? _______________
Do you have any metal implants/pacemaker? Yes _____ No ____ Explain
Do you exercise regularly? No ____ Yes ______ Explain ____________________________________
What is your daily consumption of : Water _______oz. Coffee _____ oz. Tea _____ oz. Other ___ oz.
Soft Drinks (Diet/Reg.)______ oz.
Do you have LASH EXTENSIONS? NO_______ YES__________
FEMALE CLIENTS ONLY: Are you trying to become pregnant? Yes ____ No _____
Are you due for your menstrual period within the next week? Yes ______ No _____
Do you ever experience skin break-outs? Regularly ( ) Occasionally ( ) Never ( )
What type skin do you believe you have? Normal ( ) Dry ( ) Oily ( ) Combination ( )
Do you have redness in your cheeks? Yes ______ No ___Sunburn easy? Yes ____ No ______
Do you have comedones (blackheads)? Yes _____ No _____Milia (whiteheads)? Yes____ No ____
Massage preference? Firm ( ) Light ( ) Pain threshold: Low ( ) Med ( ) High ( )
Sensitive to Touch or Pressure in any area? ______________________________________________
Brand of Personal skin care products: Soap ____________ Cleanser ________________________
Toner __________________Scrub __________________ Masque ____________________________
Moisturizer _____________________Sunscreen SPF # _____________________________________
Do you: Bruise easily ( ) Wear Contact Lenses ( ) Back Pain ( ) Any Tension or Soreness ( )
Please take a moment to carefully read the following information and sign where indicated. If you
have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated.
A referral from your primary care provider may be required prior to service being provided.
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular
tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the
pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should
not be construed as a substitute for medical examination, diagnosis, or treatment 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 massage/bodywork practitioners 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 massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my
known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any
changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to
do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in
immediate termination of the session, and that I will be liable for payment of the scheduled appointment.
I understand that the services offered are not a substitute for medical care, and any information provided by the therapist
is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is
to aid the therapist in giving better service and is completely confidential.
Client Signature _____________________________________________Date ____________________
Curr Pediatr Res 2010; 14 (1): 61-62 Acute Dystonia following brand confusion: where are we heading? Ubaid Hameed Shah, Sumaiyah Yousuf, Syed M Mehdi, Varun Department of Paediatrics and Pharmacology, J. N. Medical College, A.M.U, Aligarh Abstract A child with trivial trauma was prescribed Serronak which is a Fixed Dose Combination of serratiopeptidae (10mg) and diclof