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CLIENT INFORMATION
FIrst name
Last name
Date of Birth
Sex
Female
Male
NB
Address
City
Postal Code
Email Address
Home Phone
Emergency Contact Name
Emergency Phone
MEDICAL HISTORY
Have you ever been diagnosed with or treated for any of the following conditions?
Autoimmune disorders
Blood clotting disorder
Cancer
Diabetes
Epilepsy
Gastrointestinal disorders
Gallbladder Removed
Heart disease
High blood pressure
History of Gallstones
Infections
Kidney disease
Liver disease
Photosensitivity
Skin conditions
Tumors
Thyroid disorder
Varicose veins
Do you have any other chronic medical conditions which we should know about?
Have you ever had an allergic reaction to any food or substance?
Do you have Hearing aids, Pacemaker or Hormone Pellets (where) or metal/medical devices implanted?
Have you had any recent surgeries or injuries?
Have you ever had any adverse reactions to medications or topical treatments?
Are you currently experiencing any pain or discomfort in the areas you would like to target?
Are you currently on a weight loss program?
Do you exercise? If yes, how often?
Do you consume alcohol, and if yes,
Once a month or less
2-4 times a month
2-3 times a week
4 times a week
FEMALE CLIENTS
Are you currently pregnant or nursing?
When is your next menstrual cycle due to begin?
BODY SCULPTING GOALS
Have you ever received body sculpting treatments before?
Wanting to achieve?
General Weight Loss
Slimming/Firming
Body Contouring
Cellulite Removal
What areas of your body would you like to target?
What are your specific goals for body sculpting?
By signing below, I certify that the medical history provided today is accurate and complete to the best of my knowledge.
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