Health HistoryThe 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 No2. Have you undergone any surgery within the past 9 months?* Yes No3. 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 Above4. List all medications & vitamins taken regularly:Medications:*Vitamins:*5. Do you have any allergies? If YES, please list:* Yes NoIf YES, please list:*6. Answer the following:Do you smoke?* Yes NoHave you ever had a chemical peel?* Yes NoDo you use Retin-A?* Yes NoDo you use Accutane?* Yes NoHave you used any other acne drugs?* Yes NoDo you follow a restricted diet?* Yes NoDo you exercise regularly?* Yes NoDo you have a regular sleep pattern?* Yes NoHave you had your hair frosted, highlighted, or chemically lightened?* Yes NoDo you wear contact lenses?* Yes NoDo you have metal implants or a pacemaker?* Yes No7. With what temperature water do you cleanse?* Cold Warm Hot8. Do you have any specific skin problems pertaining to your face? If YES, specify:* Yes NoIf YES, please specify:*9. Do you have any specific skin problems pertaining to your body? If YES, please specify:* Yes NoIf 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 NoIf YES, please specify:*OIL SECRETIONDo you experience breakthrough, oily shine during the day?* Yes NoDo you experience breakouts?* Yes NoMOISTURE HYDRATIONHow much plain water do you consumedaily?*OuncesDo you take laxatives or diuretics?* Yes NoHow 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 AboveDo you use sunblock? If YES, what SPF?* Yes NoIf YES, what SPF?*CAPILLARY ACTIVITYDo you burn easily in moderate sunlight?* Yes NoDo you blush easily when nervous?* Yes NoDo you have a tendency toward redness?* Yes NoNERVE ACTIVITY4>What do you consider your pain threshold to be?* Low Medium HighHave you ever experienced any claustrophobia?* Yes NoWhat type of massage pressure do you prefer?* Low Light Medium Firm Very FirmHave you had any recent injuries? If YES, explain:* Yes NoIf YES, explain:*Are there any areas that require special attention? If YES, explain:* Yes NoIf YES, explain:*Are there areas of your body that you would prefer your therapist avoid? If YES, specify:* Yes NoIf 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 NoAre you pregnant or trying to become pregnant?* Yes NoMALE CLIENTS ONLYHow do you typically shave?* Wet DryDo you experience irritation from shaving?* Yes NoDo you experience ingrown hair?* Yes NoDate* 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.