<p>CLIENT PROFILE</p><p>Strictly Private and Confidential</p><p>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.</p><p>Arrival Date: ______Departure Date: ______Purpose of Visit: Treatments Only Day Guest Spa Evening Guest Stay Guest (please tick)</p><p>Name (please print):______Title:______</p><p>Address: ______</p><p>______Post Code: ______How did you hear of us? ______</p><p>Home Telephone #:______Mobile Telephone #:______</p><p>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.</p><p>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. </p><p>(If you are unsure please discuss with your therapist any medical conditions you feel may affect your treatment)</p><p>Please state below: ______</p><p>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: ______</p><p>Have you ever had a reaction to the following:  Cosmetics  Food e.g. Nuts  Fragrance </p><p>Female Clients Only Are you pregnant or trying to become pregnant?  Yes  No Are you breastfeeding?  Yes  No Are you menstruating?  Yes  No</p><p>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. </p><p>Client Signature: ______Date: ______</p><p>FOR SPA USE ONLY </p><p>Treatment Specific Questions Therapist’s Name: ______</p><p>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)</p><p>FACIAL</p><p>Describe your skincare routine ______</p><p>Do you have specific concerns you would like addressed? ______</p><p>Do you suffer from skin sensitivity? Eczema / Dermatitis / Psoriasis ______</p><p>Skin Surface: Dry / Dehydrated / Oily T-zone / Shiny / Redness / Blemishes / Blackheads / Open Pores / Pigmentation / Milia / Acne </p><p>Skin Specific: Lack of Firmness / Fine lines / Wrinkles / Crow’s Feet / Sun-damage</p><p>Treatment: ______</p><p>Recommendations: ______</p><p>BODY</p><p>Describe your body care routine ______</p><p>Do you have specific concerns you would like addressed? ______</p><p>Skin Surface: Dry / Flaky / Oily Back / Redness </p><p>Skin Specific: Lose skin / Cellulite / Fatty Deposits / Aches & Pains (state area) ______</p><p>Areas: Abdomen / Buttocks / Thighs / Hips / Back of Arms </p><p>Any areas you would prefer not to be worked on? ______</p><p>Treatment: ______</p><p>Recommendations:______</p>