AQUA_Intake_Form_A_10 Nov 2012

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
 Chronic Headaches or Migraines
 Insomnia
 Muscle Spasms
 Osteoporosis
 Recent Surgeries_______________
Bladder or Kidney Problems
Joint Pain or Conditions
Nerve Damage
Sinus Problems
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?____________________________
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___________________________________________
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)
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
Puffy Eyes
Broken Capillaries
 Contacts
Prescription Medication(s)
Benzoyl Peroxide
Sulfur Vitamins
Fine Lines/Wrinkles
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.