Client Profile Information - DOC

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					                   The Anti-Age Spa at Leigh Ann Client Profile Information

Last Name:______________________________ First Name:___________________Birthday_____________
Address:____________________________________________ City_______________ Zip_______________
Phone_____________________ Email address__________________________Occupation________________
Emergency Contact_______________________________________ Phone_____________________________

                                         Health History
Current Medications__________________________________________________________________

Please circle any of the following you may have:
High/Low Blood Pressure              Arthritis            Epilepsy
Asthma                               Claustrophobia       Heart Disease
Scoliosis                            Diabetes             Cancer type__________________
Varicose                             Joint Problems       Immune Disorders type______________________
Pregnant                             Breast feeding       Numbness where___________________________
Fibromyalgia                         Rosacea              Osteoporosis
Migraines                            Sciatica             Metal Rods/Plates
Pacemaker                            Other Medical devices_____________________________________
Hepatitis                            Cardiac Problems     Sinus Problems
Edema                                Anxiety/Depression MS
Keloid Scarring                      HIV/AIDS
Other conditions_________________________________________________________________________
Skin conditions__________________________________________________________________________

Have you had broken bones, surgeries or injuries in last 2 years______________________________________
Circle any that apply and fill in blanks with amount per week:
Smoker________       Exercise               Sensitivity            Alcohol Consumption ______
Drugs ________       Eating Disorder        Special Diet           HRT
Menopause            Chronic Illness        Thyroid Condition      Anemia
Caffeine intake_____ Vitamins               Herbal Remedies        Chiropractor Care
                                               Skin Histology
Have you had or used any of the following? Please put dose, frequency and date last used:
Botox___________ Fillers_________           Cosmetic Surgery________ Dermatologist Care__________
Accutane_________ Retin A________           Chemical Peels__________ Laser Treatments____________
Dermabrasion______ Enzyme Peels____ Exfoliations____________ Mole Removal______________
Pre cancerous______ Lesion Removal___ Hair Removal___________ Cold Sores_________________
Hydroquinone______ Bleaching Cremes___ Tanning Beds___________ Sunless Tanning Crème_______
Topical Acne Medications_______________Recent Dental Work______ Contact Lenses

Home Skin Care Products – Name products used and frequency
Cleanser____________________ Toner___________________ Moisture_____________________
Eye Crème__________________ Serum___________________ Exfoliator____________________
Sunscreen___________________ Mask___________________ Makeup______________________

Circle Areas of Concern:
Cellulite           Wrinkles             Crows Feet           Sore Muscles
Tight Neck          Tight Shoulders      Dry Skin             Acne
Skin Elasticity        Sun Damage             Psoriasis         Eczema
Acne Scarring          Uneven Skin Tone       Other________________________________________

What 3 things would you change about your skin________________________________________________

Where do you hold your stress_____________________________________________________________

I like my pressure:    deep    medium       light   other__________________________________________

Please Initial
______I agree to avoid direct sun after treatment             ______I do not have active cold sores
______I agree to notify therapist with any concerns           ______I do not need a doctor’s release

I understand that the services offered are not a substitute for medical care and any information provided by the
therapist(s) is for educational purposes only and not diagnostically prescriptive in nature. I understand that the
information herein is to aid the therapist in providing a better service and is completely confidential. Failure to
alert the therapist of any conditions could result in unfavorable outcomes with the treatment.

As with all skin care treatments, there is no guarantee of results. Those with cold sores could have a breakout
after treatments. Because of the use of active products, it is very important that the information on this sheet be
filled out completely and accurately.

Depending on the treatment(s), I may experience some temporary stinging, warm flushing or even mild
discomfort. These effects do not usually last more than the treatment, though your skin may feel tight for a
period of time after the treatment(s). Body work may cause some soreness, bruising and tingling after treatment.
Adequate water consumption is critical.

We do require a 24 hour cancellation. If less than a 24 hour notice, we will charge 25% the cost of the service.

I fully understand and agree to the above policies and have filled the history sheet correctly and accurately. I
hereby give my consent and authorization voluntarily and release Leigh Ann Hair Color Studio and Spa as well
as the therapist(s) from any claims, implied or stated that I have or may have in the future with this of any
treatment, regardless of the results. I am stating that the treatments and precautions above have been explained
to me in detail and that I fully understand.

__________________________________________________                   __________________________
Client Signature                                                     Date

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