Client care information

Client Care Information
Name:____________________________________________________________________________________ Mailing Address: ___________________________________________________________________________ Phone: _____________________________________ Cell: _____________________________________ Email (please print clearly): __________________________________________________________________ Would you like to be included on our email mailing list? _____ Yes ____ No Birthday: ____________________ (MM/DD/YYY) Profession: ________________________________ How did you hear about us? ___ Client ___ Email ___ Postcard ___Website ___ SPA Finder ___ City Search ___ Advertisement (where?) ______________ _____ Walked By _____Other: ______________________ If referred by a client, please provide first and last name of referral._____________________________ =============================================================================== Rate your general health: ____Excellent ___ Good ___ Fair ___ Poor Are you pregnant? _____ If yes, due date: _____________ Is your pregnancy considered high risk? ________ Do you have any special skin problems pertaining to your face or body? ____Yes _____ No If yes, please specify _________________________________________________________________________ Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products? ___ Yes ___ No Do you suffer from sinus problems? ___ Yes ___ No Please list any allergies: ______________________________________________________________________ Have you ever seen a specialist for nail infection or fungus? ____Yes____No If yes, when:____________ Do you wear: ___ Contacts ___ Dentures ___ Prosthesis Other: ___________________________________ Please check any conditions you have: □ Allergies □ Carpal Tunnel Syndrome □ Circulatory Problem □ Other __________________________________ Please be advised that if any contagious disease is noticed or suspected, services will stop at that moment and it will be explained to you that you need to see a Dr. This may be an uncomfortable conversation for both parties, however, please remember, we have your best interests at heart. I have stated all of my known medical conditions and take it upon myself to keep Tranquility updated on Please sign: ___________________________________________________________ Date: ____________

Skin Care

Your Name ________________________________________________________________________________
What skin care products do you currently use?
Face: ___ soap ___ cleanser ___ toner ___ moisturizer ___ masque ___ exfoliator ___ eye products
Body: ___ soap ___ shower gel ___ scrubs ___ oil ___ body moisturizer ___ depilatory products ___ self tanner
Have you ever had chemical peels, microdermabrasion or any resurfacing treatments? ___Yes ___No
Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products? ___ Yes ___ No
Are you currently using any products that contain the following ingredients?
___ glycolic acid ___ tactic acid ___ exfoliating scrubs ___ hydroxy acid products ___Vitamin A derivatives (i.e. retinol)
Do you experience skin breakouts? ___ Yes ___No ___ occasionally
If yes, where are the breakouts located? ___hairline ___forehead ___ under eye ___chin ___ cheeks ___ jaw line
Do you experience oily shine during the day? ____ Yes ____No ___ occasionally
Do you blush easily when nervous? ___ Yes ___No
Do you have a tendency to redness? ___ Yes ___ No
Do you suffer from sinus problems? ___ Yes ___ No
Do you experience a burning, itching sensation on your skin? ___ Yes ___No
Have you ever had a reaction to any of the following?
___ cosmetics ___ medicine ___ iodine ___ pollen ___ food ___ hydroxy acids ___ animals ___ fragrance
___ sunscreens ___Other _________________________________________________________________
Do you ever experience these conditions on your skin? ___ flakiness ___ tightness ___ obvious dryness
How much plain water do you consume daily? ___________________________________________________
Are you pregnant? _____ If yes, due date: _____________ Is your pregnancy considered high risk? ________
Estheticians are licensed professionals whose primary concern is to provide superior care for their patrons. Through education and
training they are on the look-out for any potential health concerns, such as a suspicious mole, an unexplained skin rash or nail
fungus. Since they are not doctors and cannot diagnose, they can only state their concerns and recommend the advice of a physician.
Please be advised that if any contagious disease is noticed or suspected, services will stop at that moment and it will be explained to
you that you need to see a Dr. This may be an uncomfortable conversation for both parties, however, please remember, we have your
best interests at heart. I have stated all of my known medical conditions and take it upon myself to keep Tranquility updated on my
physical health.

Please sign: ___________________________________________________________ Date: ____________
Massage Therapy
Your Name: _______________________________________________________________________________ Have you ever had a professional massage? ____ Yes ___ No Primary reason for a massage: __ Stress Reduction ___ Muscular Tension ___ Relaxation Other:____________________ Rate your normal stress level: 1 (low) to 10 (high) ________ List your primary areas of discomfort or tension: _________________________________________________ Do your exercise or regularly participate in sports? ___ Yes ___ No If yes, describe the activities and frequency:______________________________________________________ Do you eat a balanced diet? ___ Yes ___ No Rate your general consumption of the following:
Have you been hospitalized in the last year? ___ Yes ___No If Yes, describe: __________________________

Please check any chronic symptoms you have:
□ Abdominal Pain
□ Other: _________________________________________________________ Please list any other conditions or health concerns that the massage therapist should be aware of. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Please be advised that if any contagious disease is noticed or suspected, services will stop at that moment and it will be explained to you that you need to see a Dr. This may be an uncomfortable conversation for both parties, however, please remember, we have your best interests at heart. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulation. It has been made very clear that massage therapy is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have. I have stated all of my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health. Please sign: ___________________________________________ Date: ______________________

Source: http://watertownspa.com/wp-content/uploads/2013/10/Client-Care-Information_r5.14.2011.pdf