Health History - Amenity Day Spa

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:*

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:*

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 SECRETION

Do you experience breakthrough, oily shine during the day?*

Yes
No

Do you experience breakouts?*

Yes
No

MOISTURE HYDRATION

How much plain water do you consumedaily?*

Ounces

Do 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 ACTIVITY

Do 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 ACTIVITY

What 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:*

FEMALE CLIENTS ONLY

Are you taking oral contraception?*

Yes
No

Are you pregnant or trying to become pregnant?*

Yes
No

MALE CLIENTS ONLY

How do you typically shave?*

Wet
Dry

Do you experience irritation from shaving?*

Yes
No

Do you experience ingrown hair?*

Yes
No

Date*

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.