Client Intake Form - Massage and Facial
Date
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Month
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Day
Year
Date
Preferred Pronouns:
She/her, They/them, He/him, etc...
Name:
*
Date of Birth
-
Month
-
Day
Year
Date
Address:
*
City, State, Zip:
*
Phone:
*
Email:
Occupation:
Referred by:
Emergency Contact:
Relationship:
Emergency Contact Phone:
Medical Information - Massage
What would you like to achieve from your treatment today?
Have you ever had a massage before?
Yes
No
What was being treated?
Musculo-Skeletal
Headaches
Joint Stiffness/Swelling
Muscle Spasms/Cramps
Strains/Sprains
Back or Hip Pain
Shoulder, Neck, Arm or Hand Pain
Carpal Tunnel Syndrome
Leg or Foot Pain
Jaw Pain/TMJ
Tendonitis/Bursistis
Arthritis
Bone or Joint Disease
Osteoporosis
Circulatory and Respiratory
Dizziness
Shortness of Breath
Fainting
Cold Feet or Hands
Swollen Ankles
Pressure Sores
Varicose Veins
Stroke
Heart Condition
Sinus Problems
High Blood Pressure
Low Blood Pressure
Skin
Rashes
Allergies
Athlete"s Foot
Warts
Moles
Acne
Digestive
Nervous Stomach
Indigestion
Constipation
Intestinal Gas/Bloating
Diarrhea
Diverticulitis
Irritable Bowel Syndrome
Crohn"s Disease
Colitis
Nervous System
Numbness/Tingling
Twitching of Face
Fatigue
Chronic Pain
Sleep Disorders
Ulcers
Paralysis
Herpes/Shingles
Cerebral Palsy
Epilepsy
Chronic Fatigue Syndrome
Multiple Sclerosis
Muscular Dystrophy
Parkinson"s Disease
Spinal Cord Injury
Reproductive System
Current Pregnancy
Previous Pregnancy
PMS
Menopause
Pelvic Inflammatory Disease
Endometriosis
Hysterectomy
Prostate Problems
Other
Diabetes
Fibromyalgia
Cancer
Surgeries
Any infectious diseases?
List current medications:
List all allergies (food, environmental, medication, etc):
Are there any parts of your body that you do not wish to be worked?
Gluteal Tissue
Pectorals
Abdominals
Hands
Feet
Face
Scalp
Back
Next
Medical Information - Skin Care
Are you using or have you used any of the following?
Retinoids (Retin-A, Renova, etc)
Benzoyl Peroxide
Hydroquinone (Lustra, Tri-Luma, etc)
Tetracycline/Minocycline
Isotretinoin (Accutane)
Steroids/Cortisone Creams
Alpha or Beta Hydroxy Acids
Topical acne or skin medications
Have you ever reacted to any skincare products?
No
Yes
If so, what kind of product and what was the reaction?
Have you seen a dermatologist in the past year?
No
Yes
Have you ever had a facial treatment before?
Yes
No
If so, when?
How is your skin during the day?
Oily all over
Shiny in T-Zone
Tight, Dry or Flaky
Red or Irritated
Normal, no issues
Combination Oily/Dry
When you sunbathe or get accidental sun, how does your skin respond?
Always burns, never tans
Burns easily, tans poorly
Burns moderately, tans gradually
Occasionally burns, tans easily
Rarely burns, tans very easily
Never burns, always tans darkly
Have you ever had any of the following?
Chemical Peel
Microdermabrasion
Dermaplaning
Laser Treatment
Cosmetic Surgery
Botox, Fillers, Injectables
Permanent Makeup
LED Light Therapy
What areas of concern do you have? (Check all that apply):
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Hyperpigmentation
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated skin
Premature Aging
Stress Reduction
Relaxation
Eyes:
Dehydrated/dry
Wrinkles
Puffiness
Dark circles
Lips:
Dehydrated/dry
Chapped/cracked
What skin care products are you currently using? (List brand where known)
Cleanser:
Toner:
Serum(s):
Day Moisturizer:
Night Moisturizer/Creme:
Exfoliator/Scrub:
SPF:
Other:
Have you recently used any self-tanning products or received spray tan treatments?
Yes
No
If so, what kind and when?
Have you used any of the following hair removal methods in the past 6 weeks?
Electrolysis
Laser
Have you had face or body waxing in the past week?
Yes
No
What SPF do you use on your face?
How often/when?
What SPF do you use on your body?
How often/when?
Have you used a tanning bed or been sun tanning in the past 2 weeks?
Yes
No
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