Skin and Body Form Skin and Body Form "*" indicates required fields Step 1 of 4 25% Personal InformationFull Name* Date of Birth* Age* Gender* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneMobile Phone*Work PhoneEmail* Occupation* How were you originally referred to Bella Via?*Select OneDr. ColvilleDr. ZavellWebsiteFriendOtherIf Friend/Other* Medical HistoryConditionsPlease check any of the following conditions that apply to you. Arthritis/Rheumatism Bursitis Diabetes Heart Problems Immune Deficiency Disease Nail/Foot Fungus Sunburn/Windburn Face Varicose Veins Asthma Cancer Eczema/Psoriasis Hepatitis Joint Problems Sciatica Thyroid Condition Wounds/Infections Back Pain Carpal Tunnel Syndrome Fibromyalgia High/Low Blood Pressure Lymph Node Removal Seasonal Allergies TMJ Blood Clots Cold Sores Frequent Headaches Infectious Disease Migraine Headaches Smoker Torn Rotator Cuff 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?*Select OneYesNoList 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?*Select OneYesNoAre you pregnant?*If yes, when is your due date? Are you breast-feeding?If not applicable, select "N/A".Select OneYesNoN/ADo 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 SpecificsWhat are your expectations of the body treatment you will receive today?*Do you prefer a light or firm touch with your massage?*Select OneLightFirmAre you interested in aromatherapy incorporated into your treatment today?*Select OneYesNoDo 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?*Select OneYesNoAre 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?*Select OneYesNoDo you get muscle cramps?*If yes, where? If no, write "no". Skin SpecificsWhat 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 Cysts Hyperpigmented Milia Perfume-Stained Small Pores Telangiectasia (Broken Surface Capillaries) Asphyxiated Dry Hypopigmented Normal Psoriasis Sun-Damaged Breakouts Firm Large Pores Oily Rosacea Thick Combination Florid/Flushed Mature Oily T-Zone Saggy Uneven Comedones Freckled Melasma Patchy Dryness Sallow/Yellowed Wrinkled Are you sensitive to alcohol-based products?*Select OneYesNoHave 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?*Select OneYesNoAre 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?*Select OneYesNoHave you shaved your face within the last 3 to 5 days?*Select OneYesNoThe "Before" and "after" photographs from your procedure(s) may be used anonymously on our website or in our brochures for advertising porposes.*YesNoConsentI 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.