Guest Intake Form Name* First Last Gender*FemaleMaleIs this your first visit with us?YesNo Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone NumberDo you want to recieve text messages with appointment confirmations & reminders?YesNoHome PhoneWork PhoneWhich phone is your prefered method for contact?MobileHomeWorkEmailGive us your email address if you want to receive appointment confirmations and reminders by email for future appointments. You will also receive our monthly newsletter, special offers and promotions. BirthdayTell us when your birthday is and we'll send you a special birthday coupon via email each year. Date Format: MM slash DD slash YYYY What size shoe do you wear?*This tells us what size of slipper you'll need.?55 1/266 1/277 1/288 1/299 1/21010 1/21111 1/21212 1/21313 1/21414 1/2OccupationHow did you hear about us? (check all that apply) Referred by someone Drove by Internet Magazine ad Newspaper ad TV Radio Marriott / Courtyard / Fairfield Inn Other Hotel Silent or Live Auction Welcome to the Neighborhood Mailing Name of person who referred us?We will award 1,000 points to the person you list here to show our appreciation. 1,000 points is equivalent to $10 toward services or products.Name of Charity or Organization that held the auctionEmergency Contact: First Last Phone Number for Emergency Contact: Will you be recieving a massage or body treatment today?YesNo Massage InformationDo you have a preference for the gender of the massage therapist?*No PreferenceMale OnlyFemale OnlyWhen was your last professional massage?*neverLess than 1 month ago1 - 3 months ago3 - 6 months ago6 - 12 months agomore than 1 year agoWhat results do you want from your massage today? (check all that apply) Relaxation Stress Relief Sore Muscles Flexibility other Other desired results*What kind of pressure do you prefer for massage?*lightmediumfirmnot sureDo you wear any of the following? (check all that apply) Contacts Dentures Hairpiece Are you pregnant?*YesNoWhat stage of pregnancy are you in?*3rd Trimester (27 - 39 weeks)2nd Trimester (14 - 26 weeks)1st Trimester (1 - 13 weeks)Unfortunately you will not be able to receive a massage today. Massage is not permitted for women during their first trimester of pregnancy. After the first trimester, a pre-natal massage is very beneficial to reduce anxiety, decrease symptoms of depression, relieve muscle aches and joint pains, and improve labor outcomes and newborn health. Medications:What medications are you currently taking? Acetaminophen (Anacin, Tylenol) Non-steroidal anti-inflammatory drugs (NSAIDs) (Advil, Motrin, Nuprin, Ibprofen, Indocin, Relefen, Aleve) Salicylates (Aspirin, Bayer, Empirin, Doan's Pills) Steroidal Anti-inflamatories (Cortisone, Hydrocortone, Prednisone) ACE Inhibitors (Lotensin, Vasotec, Monopril, Zestril, Accupril) Anti-angina medications (Apo-ISDN, Monoket, Transderm-Nitro) Beta blockers (Inderal, Normodyne, Levatol, Tenormin) Calcium channel blockers (Norvasc, Cardizem, Cardene) Cholesterol lowering drugs (LoCholest, Lipitor, Zocor, Crestor, Tricor) Diuretics (Thalidone, Kaluril, Lasix, Bumex, Lozide) Muscle relaxants (such as Soma, Parafon, Forte, Flexeril, Skelaxin, and Myolin) Insulin (Humulin, Humalog, Lantus, Novolog) Oral glucose management drugs (Diabinase, Glocotrol, Glucophage, Precose) other List all other medications that you are currently taking and describe what you are taking them for...* Previous Surgeries and InjuriesHave you had any surgeries?*YesNoDescribe the surgeries you've had. Include year and treatment received.*Have you had any accidents?*YesNoDescribe the accidents you've had. Include year and treatment received. Health ConditionsCheck any of the following health conditions that you currently have. (check all that apply)if you are unsure, please ask. Please answer honestly, as massage may not be indicated for any of these conditions. blood clots infections congestive heart failure contagious diseases pitted edema Please check any of the following conditions that you currently have or have had in the past. (check all that apply) Muscle or joint pain Muscle or joint stiffness numbness or tingling Swelling Bruise easily Sensitive to touch/pressure High/Low blood pressure Stroke Heart attack Varicose veins Shortness of breath, asthma Cancer Neurological ( e.g. MS, Parkinson's, chronic pain) Epilepsy, seizures Headaches, Migraines Dizziness, ringing in the ears Digestive conditions (e.g. Crohn's, IBS) Gas, bloating, constipation Kidney disease, infection Arthritis (rheumatoid, osteoarthritis) Osteoporosis, degenerative spine/disk Scoliosis Broken bones Allergieis Diabetes Endocrine/thyroid condition Depression, anxiety Memory Loss, confusion, easily overwhelmed Is muscle or join pain a current or past condition?*CurrentPastExplain your muscle or join pain condition in detail including treatment received.*Is muscle or joint stiffness a current or past condition?*CurrentPastExplain your muscle or joint stiffness condition in detail including treatment received.*Is numbness or tingling a current or past condition?*CurrentPastExplain your numbness or tingling condition in detail including treatment received.*Is swelling a current or past condition?*CurrentPastExplain your swelling condition in detail including treatment received.*Is bruise easily a current or past condition?*CurrentPastExplain your bruise easily condition in detail including treatment received.*Is sensitive to touch/pressure a current or past condition?*CurrentPastExplain your sensitive to touch/pressure condition in detail including treatment received.*Is high/low blood pressure a current or past condition?*CurrentPastExplain your high/low blood pressure condition in detail including treatment received.*Is stroke a current or past condition?*CurrentPastExplain your stroke condition in detail including treatment received.*Is heart attack a current or past condition?*CurrentPastExplain your heart attack condition in detail including treatment received.*Is varicose veins a current or past condition?*CurrentPastExplain your varicose veins condition in detail including treatment received.*Is shortness of breath, asthma a current or past condition?*CurrentPastExplain your shortness of breath, asthma condition in detail including treatment received.*Is cancer a current or past condition?*CurrentPastExplain your cancer condition in detail including treatment received.*Is Neurological (e.g. MS, Parkinson's, chronic pain) a current or past condition?*CurrentPastExplain your Neurological (e.g. MS, Parkinson's, chronic pain) ondition in detail including treatment received.*Is epilepsy, seizures a current or past condition?*CurrentPastExplain your epilepsy, seizures condition in detail including treatment received.*Is headaches, migraines a current or past condition?*CurrentPastExplain your headaches, migraines condition in detail including treatment received.*Is dizziness, ringing in the ears a current or past condition?*CurrentPastExplain your dizziness, ringing in the ears condition in detail including treatment received.*Is digestive conditions (e.g. Crohn's, IBS) a current or past condition?*CurrentPastExplain your digestive condition (e.g. Crohn's, IBS) in detail including treatment received.*Is gas, bloating, constipation a current or past condition?*CurrentPastExplain your gas, bloating, constipation condition in detail including treatment received.*Is kidney disease, infection a current or past condition?*CurrentPastExplain your kidney disease, infection condition in detail including treatment received.*Is arthritis (rheumatoid, osteoarthriitis) a current or past condition?*CurrentPastExplain your arthritis (rheumatoid, osteoarthritis) condition in detail including treatment received.*Is osteoporosis, degenerative spine/disk a current or past condition?*CurrentPastExplain your oseoporosis, degenerative spine/disk condition in detail including treatment received.*Is scoliosis a current or past condition?*CurrentPastExplain your scoliosis condition in detail including treatment received.*Is broken bones a current or past condition?*CurrentPastExplain your broken bones condition in detail including treatment received.*Is allergies a current or past condition?*CurrentPastExplain your allergies condition in detail including treatment received.*Is diabetes a current or past condition?*CurrentPastExplain your diabetes condition in detail including treatment received.*Is endocrine/thyroid a current or past condition?*CurrentPastExplain your endocrine/thyroid condition in detail including treatment received.*Is depression, anxiety a current or past condition?*CurrentPastExplain your depression, anxiety condition in detail including treatment received.*Is memory loss, confusion, easily overwhemed a current or past condition?*CurrentPastExplain your memory loss, confusion, easily overwhelmed condition in detail including treatment received.*Are you currently seeing a medical practitioner?*YesNoExplain why you are seeing a medical practitioner... Massage ConsentIf I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified, medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this I give my consent to receive care.Enter "yes" to confirm your consent for receiving a massage today and aggrement to the terms listed above...* Are you age 18 or older?*YesNoParent or Legal Guardian ConsentSince you are a minor, your parent or legal guardian will need to sign a consent form. Please continue to complete the rest of this form. We will ask your parent or guardian to come to the front desk when we have the form ready. Will you be recieving a facial today?YesNo Facial QuestionnaireWhen was your last Facial or Skin treatment?Neverless than 1 month ago1 - 3 months ago3 - 6 months ago6 - 12 months agomore than 12 months agoWhat's the purpose for your visit today?* To relax and be pampered Routine cleaning minimize wrinkles improve elasticity other skin concern Describe other skin concern*Do you work outdoors?YesNoWhich of these spa/body treatments have you had in the past? Massage Salt Glow Seaweed wrap Moor mud other List the other spa/body treatments you've had.*Which of the following best describes you skin type?*I Creamy Complexion: Always burns easily, never tansII Light Complexion: Always burns, tans slightlyIII Light/Matte Complexion: Burns moderately, tans graduallyIV Matte Complexion: Seldom burns, always tans wellV Brown Complexion: Rarely burns, deep tanVI Black Complexion: Never burns, deeply pigmentedHave you every had chemical peels, laser or microdermabrasion?*YesNoWhen did you have your last chemical peel, laser or microdermabrasion* within the last 30 days 1-3 months ago more than 3 months ago Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid or Retinol/vitamin A derivative products?*YesNoDescribe your use of Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products.*Have you used any of these products in the last 3 months?*YesNoHave you used any acne medication?*YesNoWhat acne medication did you use? (check all that apply)* Proactive Accutane other other acne medication*When did you last use any acne medication*within the last month1-3 months agomore than 3 months agoWhat skin care products are you currently using? (check all that apply)* soap shower gels toner body lotions mask sunscreen eye product cleanser night moisturizer/cream day moisturizer/cream exfoliator make-up products scrubs other What brand of soap do you use?*What brand of shower gels do you use?*What brand of toner do you use?*What brand of body lotions do you use?*What brand of mask do you use?*What brand of eye product do you use?*What brand of cleanser do you use?*What brand of night moisturizer/cream do you use?*What brand of day moisturizer/cream do you use?*What brand of exfoliator do you use?*What brand of make-up products do you use?*What brand of scrubs do you use?*What other skin care products do you use?*Have you recently used any self-tanning lotions, creams or treatments?*YesNoWhat self-tanning products did you use?*Have you used any of the following hair removal methods in the past six weeks? (check all that apply) Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories Skin Concern:What areas of concern do you have regarding your skin? (check all that apply) Breakouts/acne Blackheads/whiteheads Excessive oil/shine Rosacea Broken capillaries Redness / ruddiness Sun spot / Live spot / Brown spot Uneven skin tone Sun damage Wrinkles / fine lines Dull / dry skin Flaky skin Dehydrated skin other What other skin concern do you have?*Eye Concerns:What areas of concern do you have regarding your eyes? (check all that apply) Dehydrated Wrinkles Puffiness Dark circles other What other eye concern do you have?*Lips:What areas of concern do you have regarding you lips? (check all that apply) Dehydrated Cracked/chapped lips other What other concern do you have for your lips?*Allergic Reactions:Have you ever had an allergic reaction to any of the following? (check all that apply) Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs other Explain you allergic reaction to cosmetics.*Explain you allergic reaction to medicine.*Explain your allergic reaction to food.*Explain your allergic reaction to animals.*Explain you allergic reaction to sunscreens.*Explain your allergic reaction to iodine.*Explain your allergic reaction to pollen.*Explain your allergic reaction to AHAs.*Explain your allergic reaction to fragrance.Explain your allergic reaction to shellfish.*Explain your allergic reaction to latex.*Explain your allergic reaction to drugs.*Explain your other allergic reaction.*Sunscreen usage:What SPF do you use on your face?*30 or greater20 - 3010 - 20less than 10How often do you re-apply sunscreen to you face when in the sunneverevery 3 - 4 hoursevery 1 or 2 hoursWhat SPF do you use on you body?*30 or greater20 - 3010 - 20less than 10How often do you re-apply suncreen to you body when you're in the sun?neverevery 3 - 4 hoursevery 1 - 2 hoursHave you had any recent tanning bed or sun exposure that changed the color of your skin?*YesNoExplain your recent tanning bed or sun exposure.*Injectables:Have you experienced Botox, Restylane or Collagen injections?YesNoDescribe your experience with Botox, Restylane of Collagen injections.* Female Guests Only:Are you taking oral contraceptives?YesNoWhat oral contraceptives are you taking and when?Any recent changes to or from you contraceptive treatment?*YesNoWhat changes did you make to your contraceptive treatment and when was the change made?*Are you pregnant or trying to become pregnant?*YesNoAre you lactating?*YesNoAny menopause problems?*YesNoDescribes the problems you're experiencing with menopause.*Are you undergoing any hormone replacement therapy?*YesNoDescribe you hormone replacement therapy.* Male Guests Only:What is your current method for shaving?*Razor with shaving creamElectric RazorDo you experience any irritation from shaving?*YesNoDo you have any ingrown hairs?*YesNo Thank You! 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