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Health Assessment
Please fill out the following form.
First name
Last name
Email
*
Address
Emergency Contact and Phone
Date of birth
Month
Month
Day
Year
Primary Language
English
Spanish
Other
Do you have any medical conditions we should be aware of?
Yes
No
If yes, please specify:
Have you ever been diagnosed with any of the following?
Diabetes
Heart Condition
Arthritis or joint pain
Stroke or circulation issues
Epilepsy or seizures
Skin or scalp conditions
Other
Do you take any medications that might affect your mobility, balance or alertness?
Yes
No
If yes, please list:
Do you have any allergies (including to products, latex, fragrances, etc.
Yes
No
If yes, please specify:
Do you use any mobility aids?
Cane
Walker
Wheelchair
Scooter
None
Are you able to get in and out of a salon chair or nail station with minimal assistance?
Yes
No
With help
Do you have any pain, stiffness, or swelling that might affect your comfort during your appointment?
Yes
No
Do you experience dizziness, balance problems, or risk of falls?
Often
Sometimes
Rarely
Never
If yes, please describe:
Have you or a caregiver mentioned memory changes or dementia?
Yes
No
Do you sometimes need reminders or help understanding instructions?
Yes
No
Sometimes
Is there anything we can do to make your experience easier or less confusing?
Speak slowly and clearly
Repeat instructions
Quiet environment
Allow extra time
Other
How do you prefer we communicate during your appointment?
Conversational
Quiet
With a caregiver present
Other
Are there any sensitivities we should know about (noise, touch, light, etc)?
Yes
No
Will you have your hair washed prior to our appointment?
Yes
No
Is there anything else we can do to make your visit more comfortable?
Name of caregiver/family member:
Phone Number
Relationship to client
Any notes or instructions
If yes, please describe:
Initials
*
I declare that the info I’ve provided is accurate and complete.
*
Submit
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