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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