Obgyncare.com

Caring Touch Spa
INTAKE FORM

Rate your level of stress (5=highest, 1=lowest) 5 4 3 2 1 Do you exercise? Y N If yes, how often? How many 8 oz. glasses of water do you consume daily? Do you smoke? Y N Please list any surgeries (cosmetic included): Are you currently suffering from or being treated for an infection / virus / cold / flu? Are you pregnant or lactating? Y N Are you currently taking birth control pills? Y N Do you have blood clots or bruise easily? Y N (please explain) Do you have tension or soreness in a certain area of the body, or suffer from back or neck pain? Y N (please explain) Do you have numbness or stabbing pains anywhere? Y N Are you sensitive to touch or pressure? Y N (please explain) Have you had any accidents or injuries in the last month? Y N (please explain) Please list below any medications, supplements, vitamins, or diuretics that you Please list below any allergies, including cosmetics, food, drugs, fragrance, etc. are currently taking or have taken in the last 3 months

SKINCARE INFORMATION
Have you used any of the following in the last 3 months? Retin-A Renova Retinol Tazorac Azelex Differin
If yes, how frequently?
Do you sunbathe or use tanning beds? Y N Do you use sunscreen? Y N
Do you sunburn easily? Y N Do you have a tendency to redness or flushing of the skin? Y N
Please indicate what you feel best describes or skin type: Normal Dry/Dehydrated Oily Combination Acne Prone Sensitive
(may check more than one)
What skincare products are you currently using?
(Brand/type)
Have you had any chemical peels, microdermabrasion, or any resurfacing treatments in the last week? Y N
(if yes, please indicate what treatment and when)

HEALTH HISTORY

I understand a massage therapist and/or esthetician does not diagnose illness or disease, prescribe medication, or replace a doctor’s treatment. I certify that
I have filled this form to the best of my knowledge and will update the therapist with any changes in the future. I understand that it is my responsibility to get
approval for massage therapy from my physician for any conditions that I have which are listed, BEFORE receiving massage or treatment, and that I have
answered all questions honestly, and the massage therapist and/or esthetician is not liable for any complications caused by failure to make conditions known or
get physician approval before treatment.
I understand that any illicit or suggestive behavior, remarks, or advances that could be interpreted in any sexual manner will result in the termination of the session
and I will be liable for full payment of the scheduled service, and that the therapist has the right to refuse services or end any session due to medical or personal
reasons at the therapist full discretion.
I release the establishment, its agents, and suppliers from any and all damages due to damage or injury as a result of any treatment I have requested.
Signature ____________________________________ Printed Name ________________________________________
Parent/Guardian Signature (if under the age of 18).
Name (print) __________________________ Relationship________________Signature__________________________

Source: http://obgyncare.com/pdfs/Spa_Intake.pdf