Medical & Skin History
Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name
*
First
Last
E-mail
*
We will never SPAM or sell email addresses to third parties.
Would you like to be added to my email newsletter?
Yes please.
No thanks.
Phone:
*
ex. 555-555-5555
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate:
ex. 01/05/1960
What is the best way to contact you?
*
Phone call
Email
Text
All
How did you hear about me?
Instagram
Facebook
Google
Other
Did someone refer you?
Let me know who so I can thank them.
Please list any allergies you may have or type NONE.
*
Have you ever experienced a facial massage or intraoral massage before?
*
NO
YES
Other
Do you experience any discomfort or tension in your jaw, neck, or face?(e.g., TMJ, clenching, grinding, etc.)?
NO
YES
Other
Is your discomfort on the left or right side?
LEFT
RIGHT
BOTH
Other
Is your discomfort worse in the morning, evening or all day?
MORNING
EVENING
ALL DAY
Other
Do you experience any ringing or fullness in the ears?
YES
NO
Other
Do you have any pain in your teeth that can’t be explained?
YES
NO
Other
Do you experience vertigo?
NO
YES
Other
Do you have full range of motion in your neck?
NO
YES
Other
Do you notice clicking, popping, or shifting in the jaw when opening or closing your mouth?
YES
NO
Other
Does your jaw ever feel like it gets stuck, locked or do you have difficulty opening your mouth (for example, when yawning or at the dentist?)
YES
NO
Other
Do you experience headaches or migraines? Where do you typically feel them?
Do you have any medical conditions that affect your muscles, nerves, or connective tissues ( Bell’s palsy, fibromyalgia, trigeminal neuralgia)
YES
NO
If you have had fillers, neurotoxin (botox etc.) or laser hair removal I suggest waiting two weeks before a facial massage. If you have had PDO thread the wait time is 60-90 days. Please consult with your injector or threading provider.
I understand
Are you currently undergoing any dental treatments or have any dental issues?(e.g., recent extractions, braces, dental work, etc.)
YES
NO
Is there anything else you would like me to know about your overall health or wellness that might be helpful for today’s session?
Have you had any of these health conditions in the past or present?
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart problem
Varicose veins
Arthritis
Asthma
Eczema
Epilepsy
Fever blisters
Hepatitis
Herpes
Cold sores
Immune disorders
HIV/AIDS
Lupus
Metal implants
Phlebitis
Blood clots
Insomnia
Seizure disorder
Keloid scarring
Migranes
Skin disease
Active Infection
Do you follow a regular exercise program?
YES
NO
What is your current level of stress?
Low
Moderate
High
Preparing for your appointment
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it 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 am aware that it is my responsibility to inform the massage therapist/esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Paz Amor Studio from liability and assume full responsibility thereof.
*
I understand the policy.
BUCCAL CLIENTS: I understand that my session may include gentle intraoral (inside the mouth) massage to help release jaw tension and support balance within the facial muscles, and I give my consent to receive this work. I acknowledge that gloves will be worn at all times, that I may pause or stop the treatment whenever needed, and that I will communicate any discomfort or concerns. I understand this work may feel unfamiliar or intense at times, that results are not guaranteed, and that it is not a medical treatment or diagnosis. I confirm that I do not have any contagious oral conditions (such as cold sores, infections, or open wounds) and that I have shared any relevant health information.
*
I consent to intraoral (inside the mouth) massage.
DOES NOT APPLY. FACIAL MASSAGE ONLY.
A credit card will be needed to secure your appointment. A 50% deposit will be requested at the time of booking and goes toward your treatment. This is non refundable. Please cancel or reschedule 24 hours prior to your appointment start time. If you need to reschedule, your deposit will carry over one time and you must book within 7 days. To cancel an appointment please contact Paz Amor Studio at least 24 hours prior to your appointment. If you are running late, you agree to communicate via text. You will still be required to pay the full price of the service and you may only receive the remaining time available. Please understand that there may be a client scheduled after you. 15 minutes late is considered a no show.
*
I understand the cancellation policy.
OPTIONAL: I grant permission to Paz Amor Studio to use photos of my treatment for marketing purposes on www.Pazamorstudio.com or other business listing pages such as Instagram or Facebook.
I grant permission.
No thank you.
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