*Client Intake Form* | Pure Spa Connect

First Name

Email Address

Last Name

Phone

If you answered yes to any question, please elaborate

Initials

If you have a skin condition please specify below

Do you have any known allergies or sensitivities to medications, skincare products, or ingredients? If yes, please specify:

Are you currently under the care of a physician for any reason?

Are you seeking therapy for mental heath or medical issues? If yes pleae provid deais:

Any information (medical, emotional or other) about the conditions you marked or not specified above that you feel is important for the practitioner to know.

Are you currently experiencing any swelling, edema, or lymphatic congestion? If yes, please specify the affected areas:

Do you have any areas of tenderness or sensitivity that should be avoided during the treatment?

Are you experiencing any specific skin concerns or conditions that you would like to address during the treatment?

Are you currently experiencing any skin irritations, rashes, or inflammation?

Please describe your current skincare routine, including the products you use and the frequency of use:

If you have Cardiac Conditions please specify below

Do you have a pacemaker?

Please list medications you are currently taking on a regular basis.

Do you have a history of trauma or adverse life experiences that may impact your mental well-being? If yes, please provide details:

Have you ever been diagnosed with or experienced any lymphatic disorders or conditions? If yes, please provide details:

Have you ever had manual lymphatic drainage therapy before? If yes, please provide details:

Do you have any current or past skin conditions? (Indicate all that apply) • Acne • Eczema • Psoriasis • Rosacea • Dermatitis • Fungal infections • Other (please specify):

Have you ever had a skin cancer diagnosis or precancerous lesions? If yes, please provide detail.

Have you ever had any adverse reactions or complications from skincare treatments or procedures in the past? If yes, please provide details:

Have you ever had professional facials or body treatments in the past? If yes, please provide details:

Are you using any topical skincare medications or treatments prescribed by a dermatologist or healthcare professional?

Pure Spa Wellness

Women's Restorative Wellness Practice

Pure Spa Client Intake Form