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Spa Consultation Form







Female  Male






Friends/ Family I received a Gift Card Website/Internet
Radio Magazine/newspaper Promotional Flyer
Other

General Health


Allergies Recent surgery Infectious conditions
Cancer Epilepsy Acute
Hypertension Claustrophobia Psoriasis
Rosace Skin Rashes Contact Dermatitis
Mycosis Athletes Foot  

Yes
No

Yes    weeks
No

Yes
No

Yes
No

Massage Therapy


Regularly (4-6 weeks)
Seldom (once-twice per year)
Never

Light
Medium
Medium-Firm
Firm
Very Firm



Relaxation
Tension Relief
Pain Relief
Sports Therapy

Bone/Joint disease (Arthritis) Broken/Fractured Bones Tendonitis
Arthritis Carpal Tunnel
Jaw Pain/TMJ Strains/Sprains Migranes
Tension Headaches Spasms/Cramps  

Heart Conditions Heart Palpations Varicose Veins
Deep Vein Thrombosis Blood Clots Poor Circulation
Low Blood Pressure High Blood Pressure Thyroid Condition

Chronic Pain Numbness/Tingling Chronic Fatigue
Lupus Fibromyalgia Muscular Dystrophy

Body Treatment


Regularly (Every 4-6 weeks)
Seldom (Once-Twice per year)
Never





Waxing
Please refer to waxing tips for pre/after care.


Regularly (4-6 weeks)
Seldom (once-twice per year)
I have never had waxing

Yes, I meet the requirements
No*
*If answered no, please call to reschedule your appointment as this is a contraindication to waxing hair removal.

Yes
No*
*If answered no, please call to reschedule your appointment.

Yes*
No
*If answered yes, please call to reschedule your appointment as this is a contraindication to waxing hair removal.

Yes*
No
*If answered yes, please call to reschedule your appointment as this is a contraindication to waxing hair removal.

Yes
No

No
Yes*
*If yes, please state location.

No
Yes*
*If yes, please state location

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