Brown Shugar Day Spa: Mobile Day Spa Shop::Client Forms::Confidential Health History

please fill out form completely. *Required

CLIENT INFORMATION

FIRST NAME :

LAST NAME :

ADDRESS :

CITY :

STATE:

ZIP CODE :

PHONE:

ALTERNATIVE PHONE:

DATE OF BIRTH:

/ /

EMERGENCY CONTACT:

00/00/0000 ex. 02/04/1978

EMAIL ADDRESS:

Physician/Chiropractor:

REFERRED BY:

CLIENT HISTORY

1. Is this your first body treatment? Select One: yes no *

2. What is the reason for your appointment today?:

3. What other body treatments have you had? Check all that apply: *

None	Salt Glow	Seaweed Wrap
Massage	Body Scrub	Moor Mud
Other

Specify:

4. Was it a good experience? Select One: yes no *

5, Are you currently under a physician's care for any current health problem? Select One: yes no *

If yes, what :

6. Are you pregnant? Select One: yes no *

If yes, how many weeks?

7. Are you taking birth control pills? Select One: yes no *

8. Hormone replacement? Select One: yes no *

If yes, what?

9. Do you wear contact lenses? Select One: yes no *

10. Do you smoke? Select One: yes no *

11. What is your stress level? Select One: High Medium Low *

12. What products are you currently using? Check all that apply: *

Specify:

13. Are you currently taking any medications-prescribed or over the counter including aspirin? Select One: yes no *

If yes, please list them below:

Medications:

14. Do you have any allergies to cosmetics, foods, seaweed, shellfish or drugs? Select One: yes no *

If yes, please list them below:

Allergies:

15. Are you now using or have you ever used Accutane (the acne drug) ? Select One: yes no *

If yes, when and for how long?

Please check if you are affected by or have any of the following: *

Please explain avove problem, list any other significant health issue(s) or areas of the body that are of concern.

I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential.

By submitting this form, I fully understand and agree to the above.