Medical History/ Client Information Form - The Upper Hand ...



Medical History/ Client Information Form

Name___________________________________________________________________

Address_________________________________________________________________

City_______________________________State_____________Zip__________________

Home Phone________________________________Cell_________________________________________

Email Address____________________________________________________________

Please Indicate If You Would Like To Opt-In To Receive News About Special Promotions, Event Notifications, Sales, Etc. ( ) Yes ( ) No We Do NOT Share Your Information!

Male ( ) Female ( ) DOB__________________________________________________

Emergency Contact________________________________________________________ Person(s)__________________________________Phone_________________________

How did you hear about us?

( )Phone Book Ad ( )Flyer ( )Internet ( )SpaFinder ( )Yelp ( )Referral ( )Other

If referred, who may we thank for the referral?__________________________________

Reason for today’s appointment: ( ) Relaxation ( ) Tightness ( ) Pain Relief

Is this your first time having a massage? ( ) Yes ( ) No

Medical History: Please check all that currently or have previously applied.

__High Blood Pressure ___Low Blood Pressure __Heart Disease __Stroke

__Diabetes ___Varicose Veins __Phlebitis __Cancer

__Asthma ___Headaches __Fibromyalgia __Gout

__Epilepsy/ Seizures ___Infections __Endocrine Disorder __Stress

__Skin Disorders ___TMJ Dysfunction __Cuts, bruises, fractures __Respiratory Disorders

__Gastrointestinal Problems __Arthritis ( Location________________________)

__Accidents (Date of accident:_______________ __Pregnancy (How far along are you?___________)

__Surgeries

Please explain any details regarding checks above______________________________________________

______________________________________________________________________________________

Please list any skin sensitivities, skin allergies or known “allergic reactions”__________________________

_______________________________________________________________________________________

Current Medications:___________________________________________________________________

Natural Herbal Remedies__________________________________________________________________

Are you currently under a physicians care? Yes ( ) No ( ) Reason_______________________________

Do we have permission to contact them if the need arises? Yes ( ) No ( )

Doctors Name______________________________ Phone Number _______________________________

How many caffeinated drinks per day: __________How many alcoholic drinks per day: ____________

Do you smoke? Yes ( ) No ( )

Physical Pain Assessment

Where is your pain?____________________________ How long have you had this pain?______________

What helps your pain?__________________________ What makes it worse? _______________________

On a scale of 1 to 10 (1 being no pain, 10 being severe pain) which describes your pain

Where are you now?___________

Where is your pain at it’s best?__________

Where is your pain at it’s worst?_________

Is there anything else you would like us to know?______________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

The Upper Hand Day Spa and its Massage Therapists swear and attest that they hold current and valid licenses to practice, as issued by the State Board of Licensures for the State of Georgia and we maintain all requirements thereof.

The Upper Hand Day Spa and its Massage Therapists reserve the right to refuse to perform services to the client in the event the service creates harm or discomfort to the client and/or the therapist.

The Upper Hand Day Spa and its Massage Therapists reserve the right to refuse to perform services to any client for unethical behavior prior, during and after the massage treatment. We reserve the right to discontinue the service. Client shall pay for the allotted session. No refunds will be given.

Reservations & Cancellation Policy

Reservations should be made as far in advance as possible to ensure availability of a therapist. A valid credit card or debit card is requested at the time your reservation is made. We request a 24 hour notice for individual appointment cancellations & 48 hour notice for packages. Canceling or changing appointments for groups of 3 or more requires 72 hour notice. It is very important that you call in advance if you need to change or cancel your appointment.  Any cancellations made in less than the requested time is subject to a late cancellation fee of 50% of the published price of each service. No shows will be charged 100% of the published price of each service. If a service is part of a prepaid package or gift certificate the session will be forfeited. All cancellations and no show charges are at the discretion of spa management.

In order to respect our clients busy schedules all service visits must end at their appointed times. We regret that late arrivals WILL NOT receive an extension of the scheduled service time & WILL be responsible for full service fees, if another clients appointment is impacted.

Giving your credit card number when you book your appointment is confirmation that you understand and agree to our policies.

By signing this form you agree that all information provided is true to the best of your knowledge and that you fully understand the questions asked of you, as well as the guidelines mentioned above.

Signature____________________________________________________________

Today’s Date_____________________________________

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