Name:
Address
City:
Email:
How Did You Hear About Us?
Primary Care Physician
Date:
Phone:
State:
Date of birth:
Occupation:
Zip code:
General Health
Rate your level of stress: (5= highest,1=lowest 5 4 3 2 1
Do you have any current medical conditions?
Do you wear contact lenses? Yes No
Do you smoke? Yes No How many cigarettes per day?
Do you have any allergies?
List the medications you are currently taking:
Massage Therapy
Have you ever had a professional massage before?
What type of massage do you prefer?
Is there any part of your body you do not want massaged?
Health History
Heart condition
Allergies
Headaches
Depression/Anxiety
Rashes
Diabetes
Herpes/Shingles
High blood pressure
Chronic Pain
Varicose Veins
Cancer
Pregnancy (______weeks)
Skin Care History
Are you under the care of a dermatologist? Yes No
Do you use: Accutane Retin A Renova Adapalene Other prescription skin products
Have you had a: Chemical Peel
Microdermabrasion Botox Laser Cosmetic
Surgery
Do you have any skin sensitivities or irritants?
Do you use a daily SPF?
Circle all that apply
Acne/Breakouts
Crows Feet
Dry Skin
Dark Circles
Pore Cleanse
Oily Skin
Wrinkles
Puffy Eyes
Sun Exposure History (please circle all that apply)
Do you sunburn or tan easily?
Always burn
Seldom burn
Tan easily
Never tans
Never burn
Usually burns
Tan with difficulty
Approximate skin exposure:
Minimal
Occasional
Do you use a tanning bed?
If yes how often?
Recreational
Occupational
12640 South Rt.59, Suite 108
Plainfield, IL 60585
815.609.SKIN (7546)
Moisture
Sagging Skin
What is your natural coloring?
Eyes___________ Hair___________________ Skin____________________
Goal for your massage session
relaxation
pain relief
stress reduction
I have completed this client intake form to the best of my knowledge and that the
answers I have given are correct and that I have not withheld any information that may
be relevant to my treatment. I also understand that LimeLight MedSpa And Laser Center
LLC is not responsible for any problems that may occur during any treatment if I am using
topical or oral, prescribed or over the counter medications.
Signature:
Print Name:
Date:
12640 South Rt.59, Suite 108
Plainfield, IL 60585
815.609.SKIN (7546)