GUEST INFORMATION Name / Last Name
Mobile / Telephone
Date of Birth (DD/MM)
HEALTH HISTORY
Please indicate which of the following applies to you. This information will assist us in achieving the best results for your treatment. (Check all applicable) Please note that this form will be retained and reviewed with a therapist on future visits. It is the client’s responsibility to advise of any changes.
Arthritis Cancer Thyroid Condition Hemophilia Claustrophobia
Wears contact lenses High/Low Blood Pressure Heart Disease/Surgery Frequent Headaches/Migraines
Recent Injury/Illness Skin Condition/Irritation Hypersensitive Skin Joint Pain/Problems
Sensitivity/Allergies Metal Implants or Pacemaker Diabetes/Loss of Sensation Sun Exprosure in Last 3 Days
Sleep Disorder
Are there any sensitivities or food or product allergies that we should know that might affect your treatment?
If so which Trimester are you in: 2nd 3rd (For the safety of you and your baby, the only treatment we can perform for women in their first trimester is facials.) Are you currently pregnant? Yes No Have you had any surgery or plastic surgery within the past year? (Please specify) 1st
What kind of pressure do you prefer? Light MASSAGE & BODY TREATMENT
Medium Deep
Is this your first massage/body treatment?
Yes
No
Which areas would you like the therapist to focus on? Neck and Shoulders
Back
Legs
FACIAL TREATMENT
How would you classify your skin?
Dry
Sensitive Oily
Combination
Acne
Normal
Please note if you use or have recently used any of the following products this may negatively affect your treatment
Retin A Alpha Hydroxy Acid Renova Accutane
Have you had any of the following lately? If yes, please indicate how long ago? Chemical Peel
Microdermabrasion
Laser Treatment
Surgery
Facial Waxing
DISCLAIMER
You may experience some symptoms as a result of massage/body treaments such as muscle stiffness and / or soreness, slight headache, nausea and possible isolated discoloration of the skin.
Is there anything else we should know that might affect your treatment?
Guests must be 12 years or older to receive massage/body treatments. Parental Wavier of Liability must be completed for guests 17 - 12 years of age.
I understand that if I am currently taking any medication, it is my responsibility to confirm with my doctor that it is not contraindicated by the spa treatments I am about to receive.
Is there anything else we should know that might affect your treatment?
I declare the above information is reflecting my current health condition and I agree that my questionnaire will be kept on file according to local laws.
Guest Signature
Date
/ /
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