Spa Client Medical History Questionnaire

Full Name Date of Birth Phone Number Email Address Address

Emergency Contact

Name Phone Number

Medical History

Do you have any current medical conditions? Are you allergic to any products or ingredients? Are you currently under the care of a physician? Yes No List any medications you are currently taking Skin concerns or goals

Lifestyle Information

Do you smoke? Yes No Do you drink alcohol? Yes No How often do you exercise?

Any other information you wish to share