How did you hear about us? ( referral )
Speed mapping you started with La Ritz Spa and Salon's skin health system.
2.) Have you ever used professional grade skin care products before Yes or No pls specify
4.)Have you ever had a chemical peels, laser, microdermabrasion?
5.) Which of the following best describes your skin type?
6) What areas of concerns do you have your:
EYES and LIPS
8.) do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A products? Yes or No
9.) Have you used an acne medication? Yes Or No
10.) Have you experienced Botox, Restylane or Collagen Injections?
FEMALE CLIENT ONLY
12.) Are you pregnant or trying to become pregnant? Yes or No
13.) Any menopause issues? Yes or No specify
14.) Are you undergoing hormone replacement surgery? Yes or No Specify
MALE CLIENT ONLY
16.) Do you experience irritation from shaving? Yes or No Ingrown hairs? Yes or No
Please put your signature and date.
Male / Female
Please describe any experience with massage:
Reason for today's visit:
How did you hear us? (referral?)
Medical History: Please Check All That Apply:
Would you like light ,medium, or deep pressure during your massage?
Please list any allergies:
Are you currently under a physicians care? ( ) Yes ( ) No Why ?
Do we have permission to contact them if the need arises?
Please put your Doctor's name, phone and affix your signature.
Please answer the question below
Please choose whether you are taking any of the following medications.
Are you under the care of a Dermatologist?
Please indicate below the date of your most recent?
Please affix your signature below
Do you experience fatigue or low energy levels especially around 3 pm in the afternoon?
Do you experience brain fog, lack of concentration and or poor memory?
Do you eat fatty foods,fast foods, and pre -prepared foods, or fried foods on a regular basis?
Do you drink sodas and coffee during the day to get yourself going?
Do you smoke cigarette?
Do crave or eat sugary snacks, candies, or desserts?
Do you have less than 2 bowels movement per day?
Do you feel sleepy after meals,bloated, and or gassy?
Do you experience heartburn or indigestion after eating?
Are you over weight or do you rarely exercise?
Do you experience reoccuring yeast or fungal infections?
Do you experience frequent headaches or migraines?
Do you have arthritis aches,and pain stiffness?
Do you take prescriptive medicines on a regular basis?
Do you have prescriptive sedatives, or stimulants?
Do you live with or near polluted air,water, or other environmental pollution?
Do you use fluoridated toothpaste or drink flouridated/chlorinated water?
Do you experience depression or mood swings, ( mental highs or lows?
Do you have bad breathe or excessive body odor?
Do you have food allergies or bad skin?
Are you showing signs of premature aging?
Have you ever used an internal cleansing product or followed a complete internal cleansing program?
If any of these conditions exists then FOOT DETOX is not for you:
Please affix your signature and date:
Email Address *
List any medications you have been taking in the past 6 months
Have you received chemotherapy or radiation in the past year?
Have you ever had an allergic reaction to any of the following (please circle)?
Have you ever had a cold sore? Yes No*
Have you ever had one of the following ?
What are the main concerns relating to your eyebrows?
What would you like to improve about your eyebrows? Consider shape, color, density, thickness…
Note pigments, blades, techniques used for this client
Please read the following statements carefully.
I have received after care information and I’m fully aware of the aftercare procedures*
Reason for Visit
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, vaginal/yoni steam baths may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
© 2017 La Ritz Spa & Salon