Spa Therapy Intake Form Spa Therapy Intake Form Name * Phone * Email * Date of birth * Emergency Contact * Emergency Contact Phone Number * Preferred Primary Contact Method Phone Call Text Message Email Have you had a professional massage or facial before? Yes No If yes, how often? If yes, please explain? Do you have any difficulty lying on your front, back, or side? Yes No Do you have any allergies to oils, lotions, or ointments? Yes No If yes, please explain? Are you currently taking any medication? Yes No If yes, please list medications. Have you been tested for COVID-19? Yes No If yes, what type of test did you have? When was your test? What were the results? Have you been in places with a high infection rate within the last two weeks (e.g., state designated ?hotspots?)? If yes, please explain. Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic: Fever Chills Cough Sore throat Diarrhea, digestive upset Nasal, sinus congestion Loss of sense of taste or smell Fatigue Shortness of breath Sudden onset of muscle soreness (not related to a specific activity) Rash or skin lesions (especially on the feet) Do you have any new discomfort with exertion or exercise? Do you have any new discomfort with exertion or exercise? Please check any condition listed below that applies to you: Diabetes Back/Neck problems Varicose Veins Osteoporosis Epilepsy Headaches/Migraines Heart Condition High/Low blood pressure Deep vein thrombosis/Blood clots Joint Disorder/Rheumatoid Arthritis Osteoarthritis/Tendonitis Cancer Fibromyalgia TMJ Carpal Tunnel Syndrome Contagious skin condition Open sores or wounds Easy bruising Recent accident or injury Recent fracture Recent surgery Sprains/Strains Current Fever Swollen Glands Are you pregnant? If so, how many months? Please explain any condition that you have marked above: Is there anything else about your health history that you think would be useful for your practitioner to know to plan a safe and effective massage session for you? Digital Signature of Client * Today Date * Digital Signature of Parent / Guardian (if applicable) * Today Date * If you are human, leave this field blank. Submit
