ShellEase Body Remedials
Consultation Form
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about this service?
List any medications, supplements, or herbal remedies you currently take:
Please list allergies or sensitivities:
*
Please list Injuries or surgeries:
*
Have you ever received professional body care treatments?
Please Select
Yes Massage
No Massage
Yes Physical Therapy
No Physical Therapy
No Both
Yes Both
Preferred Massage Pressure?
What are your specific concerns at this time regarding your pain?
What is your stress level right now?
Low
Average
Somewhat Stressed
Very Stressed
What do you consider your skin type?
Normal
Oily
Acne
Dry
Aging
Combination
Sensitive
Rosacea
Other
Please check all that apply.
*
Pregnant
Postpartum
Neck Pain
Back Pain
Headaches
High Blood Pressure
Bruise Easily
Diabetes
Seizures
Knee/Leg Pain
Jaw Pain / Clenching/ Grinding
Metal Implants
Fibromyalgia
Used Retin -A within the past 10 days?
Car accident
If yes, Date of injury __________
Other
What is your goal for this session?
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Appointment
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