Health History Form

Welcome to W style Beauty. An accurate health history is important to ensure that it is safe for you to receive treatments. If your health status changes in the future, please let us know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment.

First Name

Last Name

Date of Birth : MM/DD/YY

Occupation

Phone Number

Email

Address

Unit #

City

Province

Postal Code

●Previous history of massage therapy?

No

Yes

●Previous history of facial treatments?

No

Yes

PLEASE INDICATE CONDITIONS YOU ARE EXPERIENCING OR HAVE EXPERIENCED (SELECT ALL THAT APPLY)

●Abdominal/Digestive problem, Hernia

●Accutane ( Use within last year)

●Acne and Acne Scaring

●Allergies (latex, foods, aspirin, other) If yes please specify below

●Arthritis, Muscle/Joint pain

●Birth Control( specify below)

●Blood Disorder

●Botox/Fillers ( Date of the last treatment )

●Claustrophobia

●Contact Lenses

●Epilepsy

●Diabetes

●Fungus

●Gynecological Conditions, Irregular Menstruation,etc

●Headaches/Migraines

●Heart Conditions/Disease,Stroke

●Herpes/Warts( genital/oral)

●History of Cancer, Precancerous Lesions

●History of High/Low blood pressure

●History of Mental Illness, Anxiety/Depression/Fatigue

●Infectious Disease ( HIV, STD,etc)

●Keloid Scaring

●Melasma, Hypo/Hyper Pigmentation

●Metal Implants, Plates, Pins

●Numbness, Loss of sensation

●Pacemaker / Similar Device

●Phlebitis,Varicose Veins

●Pregnamcy , Attempting, Nursing

●Recent Surgeries ( date )

●Respiratory conditions, Asthma, Bronchitis, ets

●Skin Cinditions,Eczema, Psoriasis, Dermatitis, Rosacea

●Skin sensitivities/Easy Bruising

●Thyroid disorder

●Vitamins/Supplements

●Other Current Medications

●Do you have a primary complaint ? If yes Specify below

No

Yes

●Present involvement in other healthcare?

●Surgery - Date (MM/YY) and Nature

●I hereby release W style Beauty, and the owner of the Spa from any and all claims, actions, costs, expenses and or damages, including attorney’s fees, that I might have now or in the future for any injuries or damage arising of or in any manner resulting from my use of all spa facilities and services while in the W style Beauty. Such release is to be binding upon my heirs, successors, and assigns. I am fully knowledgeable as to the use of equipment and facilities as well as my own physical limitations, while using any spa facility, and I agree to use such equipment at my own risk, without supervision. I am fully aware that individuals with heart ailments, high blood pressure, pregnant women, or anyone sensitive to heat, are not advised to use equipment or heated facilities.

Date MM/DD/YY

Signature

Thank you !