Comprehensive Intake Form - Initial Visit General Services

Comprehensive Intake Form

Initial Visit General Services
General Information
Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Media Handles
Occupation
Emergency Contact
Emergency Phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?

Other
Please share the name of the family member, friend, colleague, or social media platform.
Would you like to be added to our email list for specials and discounts?
What brings you to Spa Life Sanctuary today :)
Medical History
Check all conditions that apply. (Past and current conditions)

Other
Do you have a metal implant? If so, where and how large? If not, mark "N/A"
Are you prone to cold sores/fever blister
Are you pregnant or trying to become pregnant?
YesAre you in any of the following stages?
List all medication, herbs, and supplements you are taking, including contraception and homornal therapy. (Write N/A if not applicable.)
Have you had any facial or dermatology services in the past 30 days? If yes, please explain. (Write N/A if not applicable)
Have you used Retin-A, Renova, AHAs or Retinal/Vitamin A products in the last three months? If yes, please explain. (Write N/A if not applicable)
Have you received Botox, Restylane, or Collogen injections in the last 6 months?
Have you had an allergic reaction to any of the following? List any details and /or and other allergies you have under the "Other" option.

Other
Provide specific details about your allergies here. Mark "N/A" if it does not apply.
Skin Care and Characteristics
What are your skin health goals?
What would like to achieve from your treatments?
How would you describe the skin on your face?
On a scale of 1 - 5, how sensitive is your skin? (5= Extremely)

1

2

3

4

5

1 is Worst, 5 is Best
What is your Fitzpatrick Skin Type?
What skin care products are you currently using? List names if known.
Cleanser
Soap
Shower Gel
Exfoliator
Scrubs
Mask
Day Moisturizer
Night Moisturizer
Eye Products
Toner
SPF/Sunscreen and number indicating protection level
Cosmetics/Makeup
Other
If you use SPF / sunscreen on your face, how often do you use it?
Have you recently used any self-tanning lotions, creams, or treatments? If yes, please explain. (Write "N/A" if not applicable)
Have you recently had any tanning bed or sun exposure that changed the color of our skin? If yes, please explain. (Write "N/A" if not applicable)
Have you used any of the following hair removal methods in the past six weeks? (Check all that apply)

Other
What areas of concern do you currently have regarding your skin? Check all general skin conditions that currently apply.

Other
Eyes (skin around the eyes)

Other
Lips

Other
Life Style

The insights gained from the following questions will help Spa Life Sanctuary better support you in achieving your skin health goals.
Are you experiencing any conditions? (please select all that apply)
Please share more about any conditions you may be experiencing.
How many glasses of water do you drink per day?
How many caffinated drinks (i.e. coffee, tea, energy drinks, soda, etc.) do you drink per day?
Which foods do you consume on a regular basis?

Other
How many hours of sleep do you get per night?
How much time do you spend outdoor each day?
Do you smoke or use CBD? (check all that apply)

Other
What do you do to relax?

Other
How many sessions of focused exercise do you have per week? At least 30 minutes per session)
What is your stress level on a scal of 1 to 5?

1

2

3

4

5

1 is No Stress, 5 is High Stress
Acknowledgment
I understand and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand that the treatments I receive here are voluntary, and I release this Spa Life Sanctuary LLC and/or the technician from liability and assume full responsibility thereof.
Signature
Date

MonthDayYear
Date
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