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 Diabetes Joint Pain or Conditions Nerve Damage Pregnancy Sinus Problems 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 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.