General Health History Form

*First Name
*Last Name
*Email
*Cell Phone Number
*Cell Phone Carrier
*Home or Work Number
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Today’s Date:
*Birthday
*Age
*Gender	Not SpecifiedMaleFemale
*Occupation
*Do you wear glasses or contact lens?
*Emergency Contact Name
*Emergency Contact Phone
*Emergency Contact Relationship
*Any known allergies/sensitivities (seasonal/environmental, drugs, product, food, ingredients, etc)	required
*How did you hear of us? If internet, specify as to what you searched for.	required
*Is this your first spa experience?	required
*What are your wellness goals?	required
*What types of wellness treatments and/or information are you interested in?	required
*Musculoskeletal Issues? (Choose one here, type others below.)
*List other musculoskeletal issues	required
*Skin Issues? (Choose one here, type others below.)
*List other skin issues	required
*Digestive Issues? (Choose one here, type others below)
*List other digestive issues	required
*Circulatory Issues? (Choose one here, type others below.)
*List other circulatory issues	required
*Nervous System Issues? (Choose one here, type others below.)
*List other nervous system issues	required
*Respiratory Issues? (Choose one here, type others below.)
*List other respiratory issues	required
*Endocrine Issues? (Choose one here, type others below.)
*List other endocrine issues	required
*Reproductive Issues/Conditions? (Choose one here, type others below.)
*List other reproductive issues	required
*Psycological Issues? (Choose one here, type others below.)
*List other psycological issues	required
*Urinary Issues? (Choose one here, type others below.)
*List other urinary issues	required
*Do you have any infectious or other disease? Explain.	required
*Surgeries: List types & approximate dates/years.	required
*List any accidents where you were injured & give approx dates	required
*Are you currently seeing a medical doctor, chiropractor, or natural medicine doctor? Explain.	required
*Any special instructions or information we should be aware of when attending to you?	required
*List & give purpose of any medications, including OTC meds.	required
*What supplements do you take and for what purpose?	required
*Please list the brand of supplements you take. (Do not include drugs.)	required
*Do you use illegal drugs (non-judgmental, only for us to know the effects of our treatments)?	required
*How often & how much alcohol do you consume?	required
*How often & how much do you smoke?	required
*What appliances do you have in or on your body? (Choose one, type others below.)
*List other appliances in/on your body	required
*What type of exercise or sports activity do you participate in & how often?	required
*Type your full name to indicate understanding & agreement of all of our spa’s policies.

General Health History Form

Love Thyself Day Spa

Love Thyself Day Spa

972 644 4065