CLIENT PROFILE CARD Today’s Date: ___________________Date of Birth _____/_______/____________ Name:___________________________________________ Occupation:___________________________ Address:_______________________________________________________________________________ City/State/Zip:_________________________________________________________________________ Email:_______________________________________________________________________________ Bus Ph: ( ) _________________________ Res Ph: ( ) ___________________________________ Cell Ph: ( )________________________________Cell Provider:_____________________________ Emergency Contact:______________________________________Phone ________________________ Referred by:___________________________________ Have you ever had a massage? Yes___ No___ Facial? Yes___No___ PhotoRejuvenation? Yes___No___ Microdermabrasion? Yes___No_______ What is your specific concern about your skin?______________________________________________ How long have you noticed your condition?_________________________________________________ Medical: Are you currently or within the last year under any Doctor’s care? Yes____ No _________ Explain: _______________________________________________________________________________ Circle any Health Problems: Diabetes, Thyroid, Heart, Cancer, High or Low Blood Pressure, HIV/Aids, Epilepsy, Arthritis, Tendenitis, Bursitis, Nail or Foot Fungus, Urinary or Kidney Problems, Varicose Veins, Hepatis A, B, or C, Circulatory Problems, Depression, Lupus, Pacemaker, Psoriasis, Scleroderma, Fever Blisters, Eczema, Stroke, Sunburn, Anemia, Fibromyalgia, Stress related illness, Scoliosis, Chemotherapy, Radiation, Skin Disease, Hormone Problems, Cold hands or feet, Contact Lens, Blood Disorder, Blood Thinner, Artificial Implants, Phlebitis, Hyper/Hypo Pigmentation, Claustrophobia, Sinus, Headaches, Contagious Diseases, Joint Swelling, Skin Cancer, Hysterectomy, Alcoholism, Whiplash, Other_______________________________________________ Are/have you using/taking: Antibiotics, Accutane, Retin A, Glycolic or Alphahydroxy acids, Azelex, Differin, Tazarac, Tanning Bed, Diet Tablets, Smoke, Stimulants, Oral Contraceptives, Laxatives, Diuretics, Other ______________________If so, How long?___________________________________ Medications, & Vitamins – List all and why: ________________________________________________ _______________________________________________________________________________________ If you have known allergies, please list them:________________________________________________ Are you allergic to any beauty products that you know of? Yes___ No ___, If so, please let us know what they are ________________________________________________________________________ Are you allergic to: Aspirin, Glycolic, Any plants, botanicals, Nuts. If yes, please provide their names: _________________________________________________________________________ Have you undergone surgery recently? Yes____ No____Explain______________________________ ________________________________Any Numbness/Stabbing pain anywhere: _________________ Have you had recent plastic surgery? Yes ____ No ____Explain ______________________________ If you recently had surgery, do you have permission from your doctor for a facial ? _______________ Do you have any metal implants/pacemaker? Yes _____ No ____ Explain _______________________________________________________________________________________ Do you exercise regularly? No ____ Yes ______ Explain ____________________________________ What is your daily consumption of : Water _______oz. Coffee _____ oz. Tea _____ oz. Other ___ oz. Soft Drinks (Diet/Reg.)______ oz. Do you have LASH EXTENSIONS? NO_______ YES__________ FEMALE CLIENTS ONLY: Are you trying to become pregnant? Yes ____ No _____ Are you due for your menstrual period within the next week? Yes ______ No _____ Do you ever experience skin break-outs? Regularly ( ) Occasionally ( ) Never ( ) What type skin do you believe you have? Normal ( ) Dry ( ) Oily ( ) Combination ( ) Do you have redness in your cheeks? Yes ______ No ___Sunburn easy? Yes ____ No ______ Do you have comedones (blackheads)? Yes _____ No _____Milia (whiteheads)? Yes____ No ____ Massage preference? Firm ( ) Light ( ) Pain threshold: Low ( ) Med ( ) High ( ) Sensitive to Touch or Pressure in any area? ______________________________________________ Brand of Personal skin care products: Soap ____________ Cleanser ________________________ Toner __________________Scrub __________________ Masque ____________________________ Moisturizer _____________________Sunscreen SPF # _____________________________________ Other_______________________________________________________________________________ Do you: Bruise easily ( ) Wear Contact Lenses ( ) Back Pain ( ) Any Tension or Soreness ( ) Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and that I will be liable for payment of the scheduled appointment. I understand that the services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential. Client Signature _____________________________________________Date ____________________
Family Last Name _________________________ First United Methodist Church of Allen PARENTAL PERMISSION, PERSONAL LIABILITY & MEDICAL RELEASE Liability Release-- The undersigned, being the parent, guardian, or managing conservator of (youth name(s)) ___________________________________ ________________________________________ ________________________________________ Such Yout