Client Record Card
Total Page：16
File Type：pdf, Size：1020Kb
CLIENT PROFILE
Strictly Private and Confidential
Please complete and hand to reception on arrival. Please note a new profile must be completed for each visit to keep our records up to date. We advise all clients to seek medical approval from a Doctor before undertaking any of our treatments or services.
Arrival Date: ______Departure Date: ______Purpose of Visit: Treatments Only Day Guest Spa Evening Guest Stay Guest (please tick)
Name (please print):______Title:______
Address: ______
______Post Code: ______How did you hear of us? ______
Home Telephone #:______Mobile Telephone #:______
E-mail address: ______Date of Birth:______*Please note in providing your email address you will be added onto our mailing list to receive news & special offers from Moddershall Oaks. Your details will not be passed onto anyone else, & you can unsubscribe at any time.
Client History Have you had any health problems in the past or present that we need to be aware of? For example: Cancer, Diabetes, Epilepsy, Heart Problems etc.
(If you are unsure please discuss with your therapist any medical conditions you feel may affect your treatment)
Please state below: ______
Are you currently taking any medication that may affect your treatment? If yes, please specify: Yes No ______Have you undergone any surgery in the last nine months? Yes No If yes, please specify: ______
Have you ever had a reaction to the following: Cosmetics Food e.g. Nuts Fragrance
Female Clients Only Are you pregnant or trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you menstruating? Yes No
Declaration I acknowledge that I should have medical approval before undertaking anything recommended to me at Moddershall Oaks. I confirm to the best of my knowledge, that the answers I have given are correct and that I have not withheld any information that may be relevant. I confirm that Moddershall Oaks, its employees and agents are not responsible for me if any injury to health or well-being is incurred, if the medical information provided is found to be incorrect.
Client Signature: ______Date: ______
FOR SPA USE ONLY
Treatment Specific Questions Therapist’s Name: ______
Have you ever experienced any claustrophobia? Yes No Do you suffer from a back injury/pain? Yes No Do you suffer from stress/depression/tension? Yes No Do you have a muscle injury? Yes No Do you have an impairment of sensation? Yes No State: ______CONSULTATION SPECIFIC: SPA USE ONLY (TO BE COMPLETED DURING TREATMENT)
FACIAL
Describe your skincare routine ______
Do you have specific concerns you would like addressed? ______
Do you suffer from skin sensitivity? Eczema / Dermatitis / Psoriasis ______
Skin Surface: Dry / Dehydrated / Oily T-zone / Shiny / Redness / Blemishes / Blackheads / Open Pores / Pigmentation / Milia / Acne
Skin Specific: Lack of Firmness / Fine lines / Wrinkles / Crow’s Feet / Sun-damage
Treatment: ______
Recommendations: ______
BODY
Describe your body care routine ______
Do you have specific concerns you would like addressed? ______
Skin Surface: Dry / Flaky / Oily Back / Redness
Skin Specific: Lose skin / Cellulite / Fatty Deposits / Aches & Pains (state area) ______
Areas: Abdomen / Buttocks / Thighs / Hips / Back of Arms
Any areas you would prefer not to be worked on? ______
Treatment: ______
Recommendations:______