The following questionnaire provides the information that will enable us to complete
Your services and treatments safely and effectively. All information is confidential.
Thank you for your cooperation.
Name _________________________________________________
Male / Female
Birth Month & Day ____________________
Anniversary Month & Day _____________________ Occupation ________________________________________________________
Address _____________________________________________________ City _________________________ State ______________
Zip Code ___________________ Home Phone ____________________________ Cell Phone _________________________________
Work Phone _________________________ Email ____________________________________________________________________
How did you hear about us?
 Friend
 Walk-by
 Advertisement
 Phone Book
 Google
If referred by a friend, who referred you?___________________________________________________________________________
Are you currently seeking care from any healthcare professional?  Yes  No
If yes please explain: ____________________________________________________________________________________________
Please tell about your current health conditions:
 Arthritis or Bursitis
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 Chronic Headaches or Migraines
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 Insomnia

 Muscle Spasms

 Osteoporosis
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 Recent Surgeries_______________
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Bladder or Kidney Problems
Diabetes
Joint Pain or Conditions
Nerve Damage
Pregnancy
Sinus Problems
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
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Cancer
High / Low Blood Pressure
Lung Conditions
Numbness or Tingling
Recent Injuries
Do you have any other medical condition we need to be aware of?________________________________________________________
Are you currently pregnant or breastfeeding? __________If pregnant how far along are you?____________________________
MASSAGE THERAPY
Have you had a professional massage before?  Yes  No If yes, date of last massage? __________________________________
What is your desired pressure?  Light  Medium  Deep
What is your purpose for seeking Massage Therapy/Bodywork today?
 General Relaxation
 Stress Management
 Injury Recovery
 Pain Management
 Injury Prevention
 Other
Indicate area(s) of concern
Areas of the body to be avoided______________________________Reason___________________________________________
SKIN CARE/WAXING/ HYDROTHERAPY:
I, ____________________________________ consent to and authorize AQUA An Urban Spa to perform skin exfoliation, skin waxing,
facials, body treatments and other related skin care services. I understand that with any treatment certain risks are involved and that
any complications or side effects from known or unknown causes could occur. I freely assume these risks _____________(initial).
Are you under the care of a Dermatologist? If so for what reason?____________________________________________________
General Healthcare information:
 Skin Cancer
 Eczema
 Psoriasis
Please mark ALL products you are using:
 Accutane
 Cortisone
 Glycolic Acid (Peel)
 SPF




Antibiotics
Retin-A or Retinol A
Take Home Microdermabrasion
Salicylic Acid
Please mark your skin care concerns:
 Acne/Blemishes
 Dark Circles
 Reduced Elasticity
 Deep Lines




Dull Skin
Oily
Puffy Eyes
Broken Capillaries
 Contacts








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Prescription Medication(s)
Benzoyl Peroxide
E-mycin-T
Sulfur Vitamins
Fine Lines/Wrinkles
Flakiness
Large Pores
Dark Patches
Please list all food and cosmetic allergies:_________________________________________________________________
What do you hope to accomplish from today’s treatment?___________________________________________________
What skin care line are you currently using?________________________________________________________________
Are there any other concerns/conditions not listed here that should be noted?  Yes  No
If “YES”, please describe:________________________________________________________________________
The above information is accurate and true to the best of my knowledge. I understand that the therapeutic session I receive is provided
for the basic purpose of relaxation and skin care and should not be substituted for examination, diagnosis or treatment of illness. . If I
experience any pain or discomfort during a facial massage/bodywork session, I will immediately inform the therapist or esthetician. I
agree to hold harmless the spa, their respective officers, agents, directors, owners and employees from any and all claims and causes of
action which I (or the below mentioned minor)in connection with services and treatments provided at the spa.
Signature ___________________________________________ Date: ___________________________
Consent to Treatment of Minor under the Age of 17: By my signature below, I hereby authorize a Registered Licensed
Massage Therapist or Licensed Esthetician to administer massage/bodywork/skincare therapy to my child or dependant as
they deem necessary.
Signature of Parent or Guardian:_______________________________________Date:_________________________
Thank you & Enjoy your treatment.