Guest Intake Form for MG's GRAND Day Spa

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Guest Intake Form

Name*
First Last
Gender*
- Female
- Male
Is this your first visit with us?
- Yes
- No

Address
Street Address City State ZIP Code
Mobile Phone Number
Do you want to recieve text messages with appointment confirmations & reminders?
- Yes
- No
Home Phone
Work Phone
Which phone is your prefered method for contact?
- Mobile
- Home
- Work
Email
Give 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.
Birthday
Tell 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.
Occupation
How 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 auction
Emergency Contact:
First Last
Phone Number for Emergency Contact:

Will you be recieving a massage or body treatment today?
- Yes
- No

Massage Information
Do you have a preference for the gender of the massage therapist?*
When was your last professional massage?*
What 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?*
- light
- medium
- firm
- not sure
Do you wear any of the following? (check all that apply)
- Contacts
- Dentures
- Hairpiece
Are you pregnant?*
- Yes
- No
What stage of pregnancy are you in?*
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 Injuries
Have you had any surgeries?*
- Yes
- No
Describe the surgeries you've had. Include year and treatment received.*
Have you had any accidents?*
- Yes
- No
Describe the accidents you've had. Include year and treatment received.

Health Conditions
Check 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?*
- Current
- Past
Explain your muscle or join pain condition in detail including treatment received.*
Is muscle or joint stiffness a current or past condition?*
- Current
- Past
Explain your muscle or joint stiffness condition in detail including treatment received.*
Is numbness or tingling a current or past condition?*
- Current
- Past
Explain your numbness or tingling condition in detail including treatment received.*
Is swelling a current or past condition?*
- Current
- Past
Explain your swelling condition in detail including treatment received.*
Is bruise easily a current or past condition?*
- Current
- Past
Explain your bruise easily condition in detail including treatment received.*
Is sensitive to touch/pressure a current or past condition?*
- Current
- Past
Explain your sensitive to touch/pressure condition in detail including treatment received.*
Is high/low blood pressure a current or past condition?*
- Current
- Past
Explain your high/low blood pressure condition in detail including treatment received.*
Is stroke a current or past condition?*
- Current
- Past
Explain your stroke condition in detail including treatment received.*
Is heart attack a current or past condition?*
- Current
- Past
Explain your heart attack condition in detail including treatment received.*
Is varicose veins a current or past condition?*
- Current
- Past
Explain your varicose veins condition in detail including treatment received.*
Is shortness of breath, asthma a current or past condition?*
- Current
- Past
Explain your shortness of breath, asthma condition in detail including treatment received.*
Is cancer a current or past condition?*
- Current
- Past
Explain your cancer condition in detail including treatment received.*
Is Neurological (e.g. MS, Parkinson's, chronic pain) a current or past condition?*
- Current
- Past
Explain your Neurological (e.g. MS, Parkinson's, chronic pain) ondition in detail including treatment received.*
Is epilepsy, seizures a current or past condition?*
- Current
- Past
Explain your epilepsy, seizures condition in detail including treatment received.*
Is headaches, migraines a current or past condition?*
- Current
- Past
Explain your headaches, migraines condition in detail including treatment received.*
Is dizziness, ringing in the ears a current or past condition?*
- Current
- Past
Explain 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?*
- Current
- Past
Explain your digestive condition (e.g. Crohn's, IBS) in detail including treatment received.*
Is gas, bloating, constipation a current or past condition?*
- Current
- Past
Explain your gas, bloating, constipation condition in detail including treatment received.*
Is kidney disease, infection a current or past condition?*
- Current
- Past
Explain your kidney disease, infection condition in detail including treatment received.*
Is arthritis (rheumatoid, osteoarthriitis) a current or past condition?*
- Current
- Past
Explain your arthritis (rheumatoid, osteoarthritis) condition in detail including treatment received.*
Is osteoporosis, degenerative spine/disk a current or past condition?*
- Current
- Past
Explain your oseoporosis, degenerative spine/disk condition in detail including treatment received.*
Is scoliosis a current or past condition?*
- Current
- Past
Explain your scoliosis condition in detail including treatment received.*
Is broken bones a current or past condition?*
- Current
- Past
Explain your broken bones condition in detail including treatment received.*
Is allergies a current or past condition?*
- Current
- Past
Explain your allergies condition in detail including treatment received.*
Is diabetes a current or past condition?*
- Current
- Past
Explain your diabetes condition in detail including treatment received.*
Is endocrine/thyroid a current or past condition?*
- Current
- Past
Explain your endocrine/thyroid condition in detail including treatment received.*
Is depression, anxiety a current or past condition?*
- Current
- Past
Explain your depression, anxiety condition in detail including treatment received.*
Is memory loss, confusion, easily overwhemed a current or past condition?*
- Current
- Past
Explain your memory loss, confusion, easily overwhelmed condition in detail including treatment received.*
Are you currently seeing a medical practitioner?*
- Yes
- No
Explain why you are seeing a medical practitioner...

Massage Consent
If 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?*
- Yes
- No
Parent or Legal Guardian Consent
Since 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?
- Yes
- No

Facial Questionnaire
When was your last Facial or Skin treatment?
What'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?
- Yes
- No
Which 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 tans
- II Light Complexion: Always burns, tans slightly
- III Light/Matte Complexion: Burns moderately, tans gradually
- IV Matte Complexion: Seldom burns, always tans well
- V Brown Complexion: Rarely burns, deep tan
- VI Black Complexion: Never burns, deeply pigmented
Have you every had chemical peels, laser or microdermabrasion?*
- Yes
- No
When 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?*
- Yes
- No
Describe 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?*
- Yes
- No
Have you used any acne medication?*
- Yes
- No
What 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 month
- 1-3 months ago
- more than 3 months ago
What 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?*
- Yes
- No
What 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 greater
- 20 - 30
- 10 - 20
- less than 10
How often do you re-apply sunscreen to you face when in the sun
- never
- every 3 - 4 hours
- every 1 or 2 hours
What SPF do you use on you body?*
- 30 or greater
- 20 - 30
- 10 - 20
- less than 10
How often do you re-apply suncreen to you body when you're in the sun?
- never
- every 3 - 4 hours
- every 1 - 2 hours
Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
- Yes
- No
Explain your recent tanning bed or sun exposure.*
Injectables:
Have you experienced Botox, Restylane or Collagen injections?
- Yes
- No
Describe your experience with Botox, Restylane of Collagen injections.*

Female Guests Only:
Are you taking oral contraceptives?
- Yes
- No
What oral contraceptives are you taking and when?
Any recent changes to or from you contraceptive treatment?*
- Yes
- No
What changes did you make to your contraceptive treatment and when was the change made?*
Are you pregnant or trying to become pregnant?*
- Yes
- No
Are you lactating?*
- Yes
- No
Any menopause problems?*
- Yes
- No
Describes the problems you're experiencing with menopause.*
Are you undergoing any hormone replacement therapy?*
- Yes
- No
Describe you hormone replacement therapy.*

Male Guests Only:
What is your current method for shaving?*
- Razor with shaving cream
- Electric Razor
Do you experience any irritation from shaving?*
- Yes
- No
Do you have any ingrown hairs?*
- Yes
- No

Thank You!
Please click the submit button below...

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Massage Information

Medications:

Previous Surgeries and Injuries

Health Conditions

Massage Consent

Parent or Legal Guardian Consent

Facial Questionnaire

Skin Concern:

Eye Concerns:

Lips:

Allergic Reactions:

Sunscreen usage:

Injectables:

Female Guests Only:

Male Guests Only:

Thank You!