Confide Confidential Client History Form

Name_______________________________________________________________________________

Address_____________________________________________________________________________

City____________________________State__________________________Zip___________________

Main Contact #________________Secondary #________________Emergency #____________

*E-Mail Address_____________________________________________________________________

Reason for Appointment

            ○ Massage Therapy (Deep Tissue / Relaxation)                ○ Body Wrap

            ○ Spa Treatment                                                          ○ Endermatherapie (may intensify bruising)

            ○ Alpha Session                                                          ○ Body Bronzing

General Health Information

(Please note below if you have had a history of any of the following conditions.)

○ High blood pressure (If yes, is it under control with medication?)_____

○ Cardiovascular disease

○ Heart condition

○ Diabetes

○ Chest pain

○ Cancer

(If “yes” you must have a physician’s clearance before undergoing a high heat (140-180°) session

  or use of the vibratory feature of the Alpha Capsule.) 

○ Pregnant (must be past first trimester)                              ○ Headaches / Migraines

○ Varicose Veins                                                         ○ Sinus Problems                                

○ Thrombophlebitis                                                     ○ Allergies

○ Phlebitis                                                                    ○ Insomnia     

○ Circulation Problems                                               ○ Skin Disorder /Rash

○ Respiratory Problems                                               ○ Severe Lacerations                          

○ Constipation                                                             ○ Bruise easily

○ Spastic Esophagus                                                   ○ Whiplash                                         

○ Acid Reflux                                                               ○ Fractures

○ Diverticulitis                                                             ○ Paralysis                              

○ Epilepsy                                                                               ○ Plates or pins

○ Pace Maker                                                                          ○ Other health conditions we should be                                                                                                                  aware of.

Are you currently under a physicians care?  ○ Medications?  (If yes please specify)

____________________________________________________________________________________________________________________

  ○ Drink alcohol ○ Smoke ○ Caffeine ○ Recent changes in dietary habits

Massage Information:

            Have you ever had a massage before? _________________ Deep tissue? _________________

Are you aware of where you carry your tension? ______________________________________

Are you presently suffering from any pain? ___________________________________________

Occupation_______________________ Exercise frequency/ type _________________________

Areas of Focus:

 Policies:

If you are unable to keep your appointment, please respectively provide us with a 24 hr. notice in order to avoid a cancellation fee,

 gift certificates apply.

Please arrive at least 10 minuets before for your appointment so we may better serve you and our other clients.

For best results, these treatments are to be performed consecutively for the suggested period of time occasional maintenance is recommended for continued results.

Individual results may vary due to factors including, though not limited to personal habits, individual physical conditions and noncompliance with therapeutic recommendations.

Disclaimer note:

Alpha Body Spa expresses no medical claims, medical representations, or medical opinions.  References are available in support of our compilation and services upon request.

I have completed the above information form and I am in good physical condition and state. I know of no physical restrictions, conditions disabilities, or aliments that prevent me from receiving my therapy.  I certify the information provided in my client information form is true, complete, and accurate to the vest of my knowledge.

            Signature________________________________  Date_________________________

                        How did you hear about us?

                                    ○ Web        ○ Phone book         ○ Other 

○ Who may we thank for your referral?  _________________________________

Thank You for choosing us. If you have any questions or if there is anything that we can do to help you feel more comfortable and have the best experience possible, please let us know. Your request and suggestions are welcome and appreciated.

           BREATHE, RELAX, and ENJOY your time.

                                                                    In highest regards, Alpha Body Spa