First Name:

Last Name:

E-Mail:

Phone Number:

Date of Birth:

Age:

What skin care line are you currently using?:

When was your last facial?:

When was your last sunburn?:

Do you use tanning beds? Yes or No and If so why:

Do you use environmental protection daily of at least SPF 30? Yes or No:

Are you currently under a doctor's care? Yes/No:

Are you pregnant, nursing, or trying? Yes/No:

How many months:

List any prescribed medication:

Do you suffer from any skin disorders? Please Explain:

Do you experience any of the following conditions?:

Arthritis: Diabetes: Thyroid Condition:

Asthma: Heart Problems:

Chronic Fatigue:

Athlete’s Foot: Cold sores: Psoriasis:

Cancer: High/Low Blood Pressure:

Varicose Veins: Eczema:

Migraine Headaches:

Explain other:

Have you ever had a reaction to an oil, cream, or product application? Yes/No If so please explain:

Do you have any allergies? Food or seasonal? Yes/No:

Are you allergic to shellfish? Yes/No:

Have you had any surgeries? Yes/No If so please explain:

Are you on hormone therapy? Yes/No:

How many ounces of water do you drink daily?:

How would you rate your skin? Dry/Sensitive     Normal/Oily     Acne/Acne prone?:

How you feel about the overall quality of your skin:

(Bad) 1   2   3   4   5   6   7   8   9   10 (Fantastic)

Do you suffer from any neck or shoulder injuries?:

For Massage Therapy, what are your areas of concern?:

Signature ______________________________________________________________________
The information provided above is accurate. I hereby give consent for treatment, for my self or as a parent or guardian of a minor.