"Client Intake Form - the Retreat Durham"

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The Retreat Client Intake Form
PERSONAL PROFILE
Name
Date of Birth
Street Address
Day Phone
City
State
Zip
Eve Phone
Occupation
Email
MEDICAL PROFILE
Are you currently under the care of a health care practitioner? Yes
No
If yes, please specify:
List current medications/vitamins/herbs:
Injuries/accidents/illnesses/surgeries still affecting you:
Please mark any of the following that you now have or have had:
Musculoskeletal
Circulatory
Respiratory
__Bone/Joint Disease
__Heart Condition
__Asthma/Difficulty Breathing
__Tendonitis/Bursitis
__Phlebitis/Vericose Veins
__Emphysema
__Arthritis/Gout
__Blood Clots
__Sinus Problems
__Jaw Pain (TMJ)
__High/Low Blood Pressure
__Allergies, specify
__Lupus
__Lymphedema
__Other:
__Spinal Problems
__Thrombosis/Embolism
__Other:
__Other:
Skin
Nervous System
Reproductive
__Allergies, specify
__Shingles
__Pregnant, # of weeks
__Rash
__Numbness/tingling
__Ovarian/Menstrual Problems
__Athletes Foot
__Pinched Nerve
__Prostate Problems
__Herpes/Cold Sores
__Other:
__Other:
__Eczema/Psoriasis
Other:
Other
__Migraines/Headaches
__Anxiety/Depression
Additional Client Remarks/Comments:
__Diabetes
__Chronic Pain/Fatigue
__Sleep Disorder
__Cancer/Tumors
__Contagious Diseases
__Contact Lenses
__Tobacco use
The Retreat Client Intake Form
PERSONAL PROFILE
Name
Date of Birth
Street Address
Day Phone
City
State
Zip
Eve Phone
Occupation
Email
MEDICAL PROFILE
Are you currently under the care of a health care practitioner? Yes
No
If yes, please specify:
List current medications/vitamins/herbs:
Injuries/accidents/illnesses/surgeries still affecting you:
Please mark any of the following that you now have or have had:
Musculoskeletal
Circulatory
Respiratory
__Bone/Joint Disease
__Heart Condition
__Asthma/Difficulty Breathing
__Tendonitis/Bursitis
__Phlebitis/Vericose Veins
__Emphysema
__Arthritis/Gout
__Blood Clots
__Sinus Problems
__Jaw Pain (TMJ)
__High/Low Blood Pressure
__Allergies, specify
__Lupus
__Lymphedema
__Other:
__Spinal Problems
__Thrombosis/Embolism
__Other:
__Other:
Skin
Nervous System
Reproductive
__Allergies, specify
__Shingles
__Pregnant, # of weeks
__Rash
__Numbness/tingling
__Ovarian/Menstrual Problems
__Athletes Foot
__Pinched Nerve
__Prostate Problems
__Herpes/Cold Sores
__Other:
__Other:
__Eczema/Psoriasis
Other:
Other
__Migraines/Headaches
__Anxiety/Depression
Additional Client Remarks/Comments:
__Diabetes
__Chronic Pain/Fatigue
__Sleep Disorder
__Cancer/Tumors
__Contagious Diseases
__Contact Lenses
__Tobacco use
MASSAGE PROFILE
Have you ever experienced professional massage or bodywork? __Yes
__No
How recently?
What are your massage or bodywork goals?
What kind of pressure do you prefer?
__Light
__Medium
__Firm
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. I
further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, and/or
treatment; and that I should see a qualified medical specialist for any ailment of which I am aware. Because massage/bodywork
should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions and
answered all questions honestly and to the best of my knowledge. I agree to keep the practioner updated as to any changes in my
medical profile and understand that there shall be no liability on the practioner’s part should I fail to do so. I also understand that any
illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for
payment of the scheduled appointment.
Client Signature
Date
SKINCARE PROFILE
Have you ever experienced a professional facial? __Yes
__No
How recently?
Have you ever waxed before? __Yes
__No
If yes, what areas?
Have you had any of the following procedures?
__Chemical Peel
__Laser Resurfacing
__Microdermabrasion
__Removal of Melanoma
__Facial Plastic Surgery
Are you now using (or used in the past 6 months): __Accuntane
__Retin-A
__Tazarac
__Renova
__Differin
__Azelex
__Alpha-Hydroxy Acid
__Glycolic Acid
__Salicylic Acid
__Lactic Acid
Do you sun tan or use tanning beds? __Yes
__No
*Do not expose skin to sun, natural or artificial for at least 48
hours after waxing, chemical peels, and/or microdermabrasion.
My signature below certifies that I have answered the above questions honestly and to the best of my knowledge. I understand that
the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes
only and not diagnostically prescriptive in nature. I understand that waxing may result in certain side effects, such as skin
removal/tearing, scabbing, scarring, redness, bruising, swelling, tenderness, hyperpigmentation, or pimples. I also understand that if I
expose myself to the products, services, or items listed above and do not inform my practitioner, I am accepting full resposibility for
my skin’s reaction and relieve the practitioner of any liability as a result. Therefore, it is solely my responsibilty to inform my
practitioner of any changes since my last visit.
Client Signature
Date
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