Pedicure Pre-Screen

Fill out and submit this pre-screen before your pedicure appointment.

Name

First Name

Last Name

Phone

(###)

###

####

Are you a diabetic?

Yes

Do you have allergies?

Yes

If yes, please list:

Please list any current medications:

With respect to your feet and legs, which of these conditions do you experience and how often?

Cold Feet

Dry Skin

Cracked Skin

Itchiness

Peeling Skin

Sweaty Feet

Hot Feet

Blisters

Skin Fungus

Nail Fungus

Discolored Nails

Thick Nails

Tired sensation in legs

Heavy sensation in legs

Foot Odor

Callus build-up

Corns

Plantar warts

What improvements would you like to see in your feet?