Address: _______________________________________________________________ _______________________________________________________________________
_______________________________________________________________________ List phone number(s) Home: ___________________Work: _____________________Cell: ________________ E-mail address: _____________________________________ Age: _______
Date of Birth: _________________________ Female/Male: _______ Are you presently on any medication? (Please specify)
Are you taking Accutane or any other acne medications? Yes_____ No _____
If yes, for how long? _____________________________________________________ List any operations or serious illness in the past five (5) years: _______________________________________________________________________
_______________________________________________________________________ Do you suffer from any of the following: Please check (x)
Have you used/are you using Rx products or medications such as birth control pill or
hormones? _____________________________________________________ Have you had any other forms of cosmetic enhancement whether it is surgical or non-surgical – including inject-able fillers or ‘Botox’ injections? ARE YOU ALLERGIC TO LATEX? If yes, please elaborate on severity of previousreactions? ______________________________________________________
Do you have any other allergies/intolerances to foods, drugs, chemicals, essential oils etc? _______________________________________________________
Do you suffer from Depression? ___________________________________________
Describe your skin? (Circle al that apply to your skin)
What skin care products are you using at the moment?
What would you like to see improved with your skin?
What is your daily skin care routine? Do you use a high quality sunscreen/sun-block daily
or regularly? ____________________________________________________________ How much sun exposure have you had in the past? Extreme __ Moderate___ Rarely___ Do you or have you in the past used sun beds? Never____Sometimes____Regularly___ How do you rate your health at the moment? _______________________________ Do you smoke? ______ How many a day? _________ Do you drink alcohol? _______ How many glasses a week? _________ How would you rate your diet/eating habits: - Please list: - _______________________________________________________________________
_______________________________________________________________________ Are you pregnant, breastfeeding or planning a pregnancy in the near future? _______________________________________________________________________
Do you have any hormonal problems and do you suffer from PMT symptoms?
_______________________________________________________________________ Is your energy level good? _________________________________________________ How did you find out about Moments Day Spa? ________________________________
Please add any more information below if you feel should be known more about you, your lifestyle and your desired results from our treatments?
Please read carefully the following statement and sign if you are willing to continue with
The information I have given is to the best of my knowledge correct. I have not withheld any known medial or surgical state or condition.
I have been advised of the information regarding UV exposure and will inform Moments Day Spa, of any change prior to a treatment.
I understand I may require multiple treatments depending on my response to the treatment(s) to achieve optimal results. Results may vary in different skin types and skin
and hair colours and ethnic background and including hormonal changes due to age or medication(s).
I understand that I have been advised to avoid sun exposure.
I understand that there can be short term side effects and have been made aware of these.
Client’s Signature: _____________________________ Date: ____________________
Client’s Name: ____________________________
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Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 Dear Physician, Thank you for working with this patient/client as they seek admission to the Aloha House Substance Abuse Treatment. Your role is extremely important for the patient/client to be admitted to Aloha House. We are a medical y monitored detoxification and treatment program. We ha