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Personal Information

First Name*

First

Last Name*

Last

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone*

Work Phone

Email*

Occupation*

How were you originally referred to Bella Via?*

If Friend/Other*

Medical History

Conditions

Please check any of the following conditions that apply to you.

Arthritis/Rheumatism

Asthma

Back Pain

Blood Clots

Bursitis

Cancer

Carpal Tunnel Syndrome

Cold Sores

Diabetes

Eczema/Psoriasis

Fibromyalgia

Frequent Headaches

Heart Problems

Hepatitis

High/Low Blood Pressure

Infectious Disease

Immune Deficiency Disease

Joint Problems

Lymph Node Removal

Migraine Headaches

Nail/Foot Fungus

Sciatica

Seasonal Allergies

Smoker

Sunburn/Windburn Face

Thyroid Condition

TMJ

Torn Rotator Cuff

Varicose Veins

Wounds/Infections

Do you suffer from extreme stress or depression?*

If yes, please explain. If no, write "no".

Do you have circulation problems or do you bruise easily?*

List all allergies and sensitivities including medication*

If none, write "none".

Have you ever had a stroke or any other major injury?*

If yes, please explain. If no, write "no".

Do you wear contact lenses?*

Are you pregnant?*

If yes, when is your due date?

Are you breast-feeding?

If not applicable, select "N/A".

Do you participate in physical/sports activities?*

If yes, which types and how often? If none, write "none".

List all surgeries you've had in the last 5 years.*

If none, write "none".

List all medications, herbals, and vitamins you are currently taking.*

If none, write "none".

Do you have any other medical condition(s) that your technician/therapist should know about?*

If yes, please explain. If no, write "no".

Do you tan via artificial tanning beds or booths?*

If yes, when was your last visit? If no, write "no".

Body Specifics

What are your expectations of the body treatment you will receive today?*

Do you prefer a light or firm touch with your massage?*

Are you interested in aromatherapy incorporated into your treatment today?*

Do you prefer a full-body massage, or do you have specific muscle groups that you would like your therapist to focus on during your massage?*

Have you had a professional massage before?*

If yes, when? If no, write "no".

Do you have any spinal problems?*

Are you especially sensitive to touch/pressure in any specific areas?*

If yes, please explain. If no, write "no".

Do you have difficulty falling asleep at night?*

Do you get muscle cramps?*

If yes, where? If no, write "no".

Skin Specifics

What are your expectations of the skin treatment you will receive today?*

If time allows, would you like to add any extra services to your skincare procedure today, such as waxing or paraffin for the hands and/or feet?*

How would you describe your skin?

Check all that apply.

Acne Scarred

Asphyxiated

Breakouts

Combination

Comedones

Cysts

Dry

Firm

Florid/Flushed

Freckled

Hyperpigmented

Hypopigmented

Large Pores

Mature

Melasma

Milia

Normal

Oily

Oily T-Zone

Patchy Dryness

Perfume-Stained

Psoriasis

Rosacea

Saggy

Sallow/Yellowed

Small Pores

Sun-Damaged

Telangiectasia (Broken Surface Capillaries)

Thick

Uneven

Wrinkled

Are you sensitive to alcohol-based products?*

Have you ever had a peel?*

If yes, please describe the tape and your reactions to the peel. If no, write "no".

Are you currently having microdermabrasion?*

If yes, how long has it been since your last treatment? If no, write "no".

Have you recently had laser resurfacing?*

If yes, please describe type and list the approximate date. If no, write "no".

Do you have regular cosmetic injections?*

Are you currently using Accutane?*

If yes, how long have you been using it? If no, write "no".

Are you currently using Tazorac, Retin-A, Renova, or Differin?*

If yes, what strength, how long, how frequently and where do you apply it? If no, write "no".

Have you had facial waxing within the last 3 to 5 days?*

Have you shaved your face within the last 3 to 5 days?*

The "Before" and "after" photographs from your procedure(s) may be used anonymously on our website or in our brochures for advertising porposes.*

Consent

I understand that my body therapy session is provided for the basic purpose of stress reduction, relief from muscular discomfort, and for helping increasing blood, lymph, and energy circulation. I have stated all known medical conditions and I will keep the massage therapist updated on any changes regarding my health. I claim full responsibility for services rendered.

I have stated all known medical conditions and I will keep the aesthetician updated on any changes regarding my health. I claim full responsibility for services rendered.

I agree to the above statement.

Skin and Body Therapies Intake Form

Personal Information

Medical History

Body Specifics

Skin Specifics