Spa intake form - the nardella clinic

INTAKE FORM
HOW DID YOU HEAR ABOUT OUR THE NARDELLA CLINIC? MEDICAL HISTORY PRIMARY FAMILY PHYSICIAN: MAY WE HAVE PERMISSION TO CONSULT WITH PRIMARY PROVIDER? YES ___ NO ___ PLEASE LIST: CURRENT MEDICATIONS (TOPICAL & INTERNAL): PLEASE CHECK ANY & ALL CONDITIONS THAT APPLY TO YOU: ___ ALCOHOL ADDICTION HAVE YOU HAD A FAMILY HISTORY OF SKIN DISEASE? YES DO YOU HAVE A PACEMAKER? YES: __ NO: __METAL PLATES OR PINS? YES: __ NO: __ LIFESTYLE DO YOU HAVE ANY DIFFICULTIES WITH YOUR HANDS OR FEET? HOW MUCH WATER DO YOU DRINK IN A DAY? _____ CAFFEINE? ______ ALCOHOL? PLEASE DESCRIBE YOUR DIET (I.E. VEGAN, LOW CARB, ETC.) DO YOU ENJOY HOT OR SPICY FOODS? YES: __ DESCRIBE _________ NO: _____ DO YOU SMOKE? ___________IF YES, HOW MANY? ___________ HOW LONG? ____YRS HOW WOULD YOU DESCRIBE YOUR DAILY LEVEL OF STRESS? DO YOU EXERCISE REGULARLY? YES: __ NO: __ DESCRIBE: PLEASE LIST ANY OTHER INFORMATION WE MAY NEED TO KNOW ABOUT: 202, 1910- 20th Ave. NW Calgary, AB T2M 1H5 email: [email protected] Web: www.aquaterraspa.ca INTAKE FORM
FOR WOMEN: ARE YOU PREGNANT: YES: __ NO: __ IF YES, STAGE: _______ DUE DATE: _________ ARE YOU TRYING TO BE PREGNANT? _____ ARE YOU ON ORAL CONTRACEPTIVES? YES: __ NO: __ MEDICAL & AESTHETIC HISTORY ARE YOU UNDER THE CARE OF A DERMATOLOGIST? YES: __ NO: __ DERMATOLOGISTS NAME: _________________ REASON FOR TREATMENT: _____________ DO YOU TAKE DIETARY SUPPLEMENTS/VITAMINS? YES: __ NO: __ IF YES, PLEASE DESCRIBE: _______________________________________________ DO YOU TRAVEL; FOR WORK OR PLEASURE? _W / P_______ HOW OFTEN? ______________ IF YES, TYPE _____________ AREA ______________ IF YES, TYPE _____________ DATE ______________ HOW LONG HAVE YOU BEEN USING THIS MEDICATION? IF YES, AREA _____________ DATE ______________ ______________________________________________ IF YES, HOW OFTEN? _____________________ EYES__________ HAIR__________ SKIN___________ I HAVE STATED ALL MEDICAL CONDITIONS THAT I AM AWARE OF AND WILL UPDATE THE TECHNICIAN OF ANY CHANGES IN MY HEALTH STATUS. SIGNATURE: _______________________________________ 202, 1910- 20th Ave. NW Calgary, AB T2M 1H5 email: [email protected] Web: www.aquaterraspa.ca INTAKE FORM
INFORMED CONSENT
Statement of Acknowledgement
I confirm that I have the ability to accept or reject this care of my own free will and that I am not an agent of any private,
local, county, provincial or federal agency attempting to gather information without so declaring. I understand that, as a patient, I am responsible for all costs incurred as a result of the decision including, but not limited to; the cost of all procedures involved in the treatment plan, the care provider’s time, supplements, supplies and appointments missed or cancelled without sufficient notice (48 hours). I am aware that treatments are not covered through Alberta Health Care and may not be covered under private health insurance. ___________________________ SIGNATURE
DATE Witness
202, 1910- 20th Ave. NW Calgary, AB T2M 1H5 email: [email protected] Web: www.aquaterraspa.ca

Source: http://www.drnardella-nd.ca/files/spa-intake-form.pdf