Health History The following profile information is required for all clients to correctly evaluate individual needs while taking into consideration any health issues and/or concerns. This information is completely confidential and will be used strictly for the purpose of your individual treatment at Amenity Day Spa.Name* First Last Nick Name Date of Birth:* MM slash DD slash YYYY 1. Are you currently, or have you within the past year been under a physician’s care?* Yes No 2. Have you undergone any surgery within the past 9 months?* Yes No 3. Have you ever suffered from any of the following:* Cancer Diabetes Epilepsy Hepatitis HIV Thyroid Heart Problems High Blood Pressure Hormone Imbalance Hysterectomy Varicose Veins None of the Above 4. List all medications & vitamins taken regularly:Medications:* Vitamins:* 5. Do you have any allergies? If YES, please list:* Yes No If YES, please list:* 6. Answer the following:Do you smoke?* Yes No Have you ever had a chemical peel?* Yes No Do you use Retin-A?* Yes No Do you use Accutane?* Yes No Have you used any other acne drugs?* Yes No Do you follow a restricted diet?* Yes No Do you exercise regularly?* Yes No Do you have a regular sleep pattern?* Yes No Have you had your hair frosted, highlighted, or chemically lightened?* Yes No Do you wear contact lenses?* Yes No Do you have metal implants or a pacemaker?* Yes No 7. With what temperature water do you cleanse?* Cold Warm Hot 8. Do you have any specific skin problems pertaining to your face? If YES, specify:* Yes No If YES, please specify:* 9. Do you have any specific skin problems pertaining to your body? If YES, please specify:* Yes No If YES, please specify:* 10. Check all skincare products you are currently using:* Soap Toner Masque Moisturizer Scrub/Peel Other (specify) If Yes:* 11. Have you ever had a spa treatment before? If YES, please specify:* Yes No If YES, please specify:* OIL SECRETIONDo you experience breakthrough, oily shine during the day?* Yes No Do you experience breakouts?* Yes No MOISTURE HYDRATIONHow much plain water do you consumedaily?* OuncesDo you take laxatives or diuretics?* Yes No How many alcoholic beverages do you consumer weekly?* 1-3 4+ Check any of the following conditions you experience on your skin:* Flakiness Tightness Obvious Dryness None of the Above Do you use sunblock? If YES, what SPF?* Yes No If YES, what SPF?* CAPILLARY ACTIVITYDo you burn easily in moderate sunlight?* Yes No Do you blush easily when nervous?* Yes No Do you have a tendency toward redness?* Yes No NERVE ACTIVITYWhat do you consider your pain threshold to be?* Low Medium High Have you ever experienced any claustrophobia?* Yes No What type of massage pressure do you prefer?* Low Light Medium Firm Very Firm Have you had any recent injuries? If YES, explain:* Yes No If YES, explain:* Are there any areas that require special attention? If YES, explain:* Yes No If YES, explain:* Are there areas of your body that you would prefer your therapist avoid? If YES, specify:* Yes No If YES, explain:* Check any of the following to which you have had a reaction:* cosmetics pollen animals medicine food fragrance iodine AHAs sunscreen other (specify): FEMALE CLIENTS ONLYAre you taking oral contraception?* Yes No Are you pregnant or trying to become pregnant?* Yes No MALE CLIENTS ONLYHow do you typically shave?* Wet Dry Do you experience irritation from shaving?* Yes No Do you experience ingrown hair?* Yes No Date* MM slash DD slash YYYY Client Signature:*My signature below indicates, to the best of my knowledge, the information I have provided is correct and complete, and I have not withheld any information that may be relevant to my treatment.
