Cheshire Lasers Powersculpt and Powerform Treatment Consultation Form

Cheshire Lasers Powersculpt and Powerform Treatment Consultation Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
Mobile phone*
Email
example@example.com
Occupation*
Are able to phone you should we need to discuss your appointment?*

YesNo
Are we able to email you about your appointment?*

YesNo
Are you happy for us to text you about your appointment?*

YesNo
Would you like to receive our newsletter by Email (usually monthly)?*

YesNo
Where did you hear about the clinic?
Are you currently taking any medication or any supplements?*

YesNo
Are you recovering from any medical treatment or operation within the last 12 months?*

YesNo
If yes please specify the condition and the medication:
Are you currently using/used in the last 3 months any of the following?*

St Johns WortAspirinAntibioticsAnticoagulants or blood thinners eg warfarinRoaccutaneRetin AAmioderoneSteroidsNone of these
Do you have any allergies including metals, rubber silicone? If so what are you allergic to?*

YesNoOther
Is there any possibility of pregnancy or are you breast feeding?*

YesNo
Do you have any metal implants or screws, silicone implants or contraceptive devices near the area treated.*

YesNo
Do you have a Heart Condition or a Pacemaker / Defibrillator.*

YesNo
Have you had any Mesh surgery in the pelvic area or anywhere else?*

YesNo
Lifestyle & Medical History – please tick any that apply to you.*

Lack of normal skin sensationPlanning pregnancyDiabetesHigh or Low Blood PressureEpilepsyHistory of keloid formation/scarringCommunicable Diseases (Hepatitis/HIV)AutoImmune or Immune System DisordersHormonal Imbalance e.g. PCOs or Thyroid ConditionPhotosensitive conditionsSkin conditions such as Psoriasis/Eczema/RosaceaHerpes (shingles/cold sores)And skin lesions or infection in the areaDepression/AnxietyMuscular conditionCancerKidney or Liver diseaseVascular disorders /thrombosisHernia or Mesh SurgeryClaustrophobiaNone of the aboveOther
Please can you comment about above and any other medical problems not mentioned earlier.
Have you had any of the following procedures? in the last 6 months*

Chemical PeelBotoxInjectable FillersPrevious laser or IPL TreatmentSilhouette Soft Threads in the last 10 weeksNone of these
How often do you exercise?*

NeverA few times a monthOnce a weekTwice to Three times a weekFour times a week or moreOther
What is your weight, height and BMI if you know it.
When did you last exercise and what muscle groups did you target?*
How much do you smoke/day?*
How much alcohol do you consume a week ?*
Now healthy is your diet? Do you consume a lot of processed food, sugar or salt?*
What are your areas of specific concern?*
Have you ever received any body treatment previously?

YesNo
What were the results?
What are your goals/expectations for the treatment?*

Out of 5, how familiar are you with this the treatment you are interested in? *

	1	2	3	4	5

1 is Worst, 5 is Best

Out of 5, where 5 is very much and 0 is not at all. How much does your problem bother you?*

	1	2	3	4	5

1 is Worst, 5 is Best

Can you explain why it bothers you?
Where 5 is very much and 0 is not at all. How much do you think it affects the following?

Your confidence *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your social life *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your employment or role at work *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

How much does it impact you psychologically*

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Does/ will your treatment help you psychologically?*

YesNo
Does/ will your treatment help you in any other way?*

YesNoOther
Do you worry about your appearance*

YesNo
Do you suffer from anxiety symptoms or low mood or any other mental health problems?*

YesNo
Any other comments:
The information I have given is correct to the best of my knowledge, and I have not withheld any medical state or information. I will inform the IPL/Laser Technician before treatment if there has been any change (for example in medications).*

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