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BOOK YOUR APPOINTMENT
(970) 609-8899
Mesa County Health Department Rating
Rated 5 out of 5
home
Massage Services
Benefits of Massage
Massage FAQ’s
Pain Management
Microcurrent Therapy for Inflammation/Pain
Healy Device
Percussion Therapy
Skin Care Services
DermaSweep MicroDermabrasion
Bio-Therapeutic Microcurrent Technology
Cosmetic Laser Treatments
Laser Hair Removal
Pricing
Our Office
Hours & Scheduling
Products
Specials & Gift Certificates
Contact
home
Massage Services
Benefits of Massage
Massage FAQ’s
Pain Management
Microcurrent Therapy for Inflammation/Pain
Healy Device
Percussion Therapy
Skin Care Services
DermaSweep MicroDermabrasion
Bio-Therapeutic Microcurrent Technology
Cosmetic Laser Treatments
Laser Hair Removal
Pricing
Our Office
Hours & Scheduling
Products
Specials & Gift Certificates
Contact
Massage & Facial Combo Intake form
Simply complete online, or print, and bring with you to your appointment
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ALL INFORMATION BELOW IS PROTECTED BY CURRENT COLORADO STATE HIPPA REGULATIONS AND WILL NOT BE SHARED WITH ANYONE WITHOUT YOUR CONSENT.
Name
*
First
Last
D.O.B
*
Month
Day
Year
Address
*
Street Address
City
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Occupation
*
Does your job require that you work outdoors?
YES
NO
Martial Status
Single
Married
Divorced
Widow
Emergency Contact
Relationship
Phone
Were you referred to our office?
YES
NO
By whom?
What results do you expect from today's visit?
Are you taking any medication/herbs (includes aspirin, ibuprofen, supplements)? Please list.
We want to give you the best treatment possible.
To avoid stimulating or aggravating a current condition we would like to know if you have any chronic systemic illness that we should be aware of? (e.i.: Hepatitis, Epstein Barr, etc...)
Do you have any allergies to medications, lotions, detergents, cleaning products, etc?
We occasionally use aromatherapy or essential oils during our treatments. Do you have any sensetivities to any scents or products that are scented?
Have you ever had any injuries or surgeries? Please list occurance and date
Occurence
Date
Please mark below a (C) for Current condition or (P) for Past condition
Headaches/migraines
Allergies
Neck Pain
Back Pain
Spinal column disorders
Sprains/strains
Muscle/joint pain
Muscle/bone injuries
Arthritis/tendonitis
Number/tingling
Heart/circulatory disorders
High/Low Blood Pressure
Blood thinners
Diuretics
Chronic pain
TMJ
Varicose/spider veins
Diabetes
Clotting disorders
Cancer/tumors
Asthma or Lung Conditions
Indigestion/Heartburn/Hernia
Constipation/diarrhea
Crones disease
Thyroid problems
Anxiety/Stress
Menupause
PMS
Insomnia
Sinus Problems
Pregnancies
Vision problems or contacts
Dental bridges, braces
Birth Control
Skin Conditions
Acne
Rashes
Cold sores
Rosacea
Claustrophobia
Light sensetivity (skin or eyes)
Other medical conditions not listed:
Lifestyle
How many hours do you sleep per night?
How often do you exercise?
On a scale of 1 (low) to 10 (high), how would you rate your stress level?
1
2
3
4
5
6
7
8
9
10
Nutrition
Check any of the following foods that you consume and indicate how often and approximate quantities
Sugar
Spicy Foods
Dairy Products
Salty Foods
Snack Foods
Meat Products
Sugar Quantity
Spicy Quantity
Dairy Quantity
Salty Foods Quantity
Snack Foods Quantity
Meat Products Quantity
Check any of the types of fluids that you consume daily and indicate the quantities
Water
Juices
Tea
Coffee
Alcohol
Sodas
Water Quantity
Juices Quantity
Tea Quantity
Coffee Quantity
Alcohol Quantity
Soda Quantity
Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation.
Your Skin Care
Have you ever had a facial treatment before?
YES
NO
When?
Have you ever had a body spa treatment before?
YES
NO
When?
Body Spa Treatments
Select All
Massage
Salt Glow
Seaweed Wrap
Moor Mud
Body Scrub
Which of the following best describes your skin type.
Creamy Complexion
Always burns easily
Never tans
Light Complexion
Always burns easily
Tans Slightly
Light/Matte Complexion
Burns moderately
Tans gradually
Matte Complexion
Seldom burns
Always tans well
Brown Complexion
Rarely burns
Deep tan
Black Complexion
Never burns
Deeply pigmented
Do you have any special skin problems or concerns pertaining to your face or body?
YES
NO
Specify
Have you ever had chemical peels, laser or microdermabrasion?
YES
NO
In the last month?
YES
NO
Have you ever had Botox injections or filler?
YES
NO
If so, where/when?
Have you ever had permanent makeup applied?
YES
NO
If so, where/when?
Have you ever undergone plastic surgery?
YES
NO
When?
Where on your body?
What information can you provide about the procedure?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A derivative products?
YES
NO
Describe
If you have used any of the products listed below within the last 3 months, please enter the brand name where known.
Soap
Shower Gels
Toner
Body Lotions
Mask
Sunscreen
Eye Product
SPF
Cleanser
Night Moisturizer/Cream
Day Moisturizer
Exfoliator
Scrubs
Makeup Products
Other Products
Have you used an acne medication?
YES
NO
Which Drug?
Have you recently used any self tanning lotions, creams or treatments?
YES
NO
Specify
Have you used any hair removal methods in the past 6 weeks?
YES
NO
Check all that apply
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
What areas of concern do you have regarding your SKIN?
Select All
Breakouts/Acne
Uneven skin tone
Distended capillaries
Flaky Skin
Blackheads/Whiteheads
Sun Damage
Redness/Ruddiness
Dehydrated
Excessive Oil/Shine
Wrinkles/Fine Lines
Sun Spots/Liver Spots/Brown Spots
Rosecea
Dully/Dry Skin
Check all that apply.
Please explain your concern
Eyes
Check all that apply
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
Please specify
Lips
Check all the apply
Dehydrated
Cracked/Chapped lips
Other
Please specify
Have you ever had an allergic reaction to any of the following?
Please check any that apply and explain
Cosmetics
AHA's (Alpha Hydroxy Acids)
Medicine
Fragrance
Food
Shellfish
Animals
Latex
Sun Screens
Drugs
Lodine
Pollen
Other
Please explain
What SPF do you use on your face?
How often/when?
What SPF do you use on your body?
How often/when?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
YES
NO
Please specify
Have you experienced Botox, Restylane or Collagen injections?
YES
NO
Please specify
Female Clients Only
Are you taking oral contraceptives?
YES
NO
Please specify
Any recent changes to or from your contraception treatment
YES
NO
If so, what and when?
Are you pregnant or trying to become pregnant?
NO
YES
Are you lactating?
NO
YES
Any menopause problems?
NO
YES
Specify
Are you undergoing any hormone replacement therapy?
NO
YES
Specify
Male Clients Only
What is your current shaving system?
Wet Shave
Electric
Both
Do you experience irritation from shaving?
NO
YES
Ingrown hairs?
NO
YES
Are you using any type of hormone replacement therapy?
NO
YES
Specify
It is important that you drink plenty of water after a massage. Massage promotes circulation of blood, lymph and in some cases intestinal matter. Water helps clear toxins and keeps you feeling your best. It is recommended that you drink half your body weight, daily, in ounces of water. This does not mean coffee, tea, soft drinks, etc.
Please take a moment and carefully read the following information, circle relationship to client and sign where indicated.
If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to services being provided. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. Because massage/bodywork is contraindicated (should not be done) under certain medical conditions. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile.
Date
MM slash DD slash YYYY
Client, Parent or Guardian Signature
*
Prove your humanity. What letter is missing? A,B,_,D,E
*
