Cheshire Lasers Powerform Pelvic Floor Treatment Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone
Mobile phone
*
Email
example@example.com
Occupation
*
Are we able to phone you should we need to discuss your appointment?
*
Yes
No
Are we able to email you about your appointment?
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Yes
No
Are you happy for us to text you about your appointment?
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Yes
No
Would you like to receive our newsletter by Email (usually monthly)?
*
Yes
No
Where did you hear about the clinic?
Are you currently taking any medication or any supplements?
*
Yes
No
Are you recovering from any medical treatment or operation within the last 12 months?
*
Yes
No
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 Wort
Aspirin
Antibiotics
Anticoagulants or blood thinners eg warfarin
Roaccutane
Retin A
Amioderone
Steroids
None of these
Do you have any allergies including metals, rubber silicone? If so what are you allergic to?
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Yes
No
Other
Is there any possibility of pregnancy or are you breast feeding?
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Yes
No
Do you have any metal implants or screws, silicone implants or contraceptive devices near the pelvic, hip or lower spine area?
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Yes
No
Do you have a Heart Condition or a Pacemaker / Defibrillator.
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Yes
No
Have you had any Mesh surgery in the pelvic area or anywhere else?
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Yes
No
Lifestyle & Medical History – please tick any that apply to you.
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Lack of normal skin sensation
Planning pregnancy
Diabetes
High or Low Blood Pressure
Epilepsy
History of keloid formation/scarring
Communicable Diseases (Hepatitis/HIV)
AutoImmune or Immune System Disorders
Hormonal Imbalance e.g. PCOs or Thyroid Condition
Photosensitive conditions
Skin conditions such as Psoriasis/Eczema/Rosacea
Herpes (shingles/cold sores)
And skin lesions or infection in the area
Depression/Anxiety
Muscular condition
Cancer
Kidney or Liver disease
Vascular disorders /thrombosis
Hernia or Mesh Surgery
Claustrophobia
None of the above
Other
Please can you comment about above and any other medical problems not mentioned earlier.
How often do you exercise?
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Never
A few times a month
Once a week
Twice to Three times a week
Four times a week or more
Other
What is your weight, height and BMI if you know it.
How much do you smoke/day?
*
How much alcohol do you consume a week ?
*
What are your areas of specific concern?
*
Have you ever received treatment for your concern previously?
Yes
No
What were the results?
What are your goals/expectations for the treatment?
*
On a scale of 1 to 5, how familiar are you with the treatment you are interested in?
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1
2
3
4
5
Not at all familiar
Very familiar
1 is Not at all familiar, 5 is Very familiar
Out of 5, where 5 is very much and 1 is not at all. How much does your problem bother you?
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1
2
3
4
5
Not much
A lot
1 is Not much, 5 is A lot
Can you explain why it bothers you?
Where 5 is very much and 1 is not at all. How much do you think it affects the following?
Your confidence
*
1
2
3
4
5
Not at all
Very Much
1 is Not at all, 5 is Very Much
Your social life
*
1
2
3
4
5
Not at all
Very Much
1 is Not at all, 5 is Very Much
Your employment or role at work
*
1
2
3
4
5
Not at all
Very Much
1 is Not at all, 5 is Very Much
How much does it impact you psychologically
*
1
2
3
4
5
Not at all
Very Much
1 is Not at all, 5 is Very Much
Does/ will your treatment help you psychologically?
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Yes
No
Does/ will your treatment help you in any other way?
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Yes
No
Other
Do you suffer from anxiety symptoms or low mood or any other mental health problems?
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Yes
No
Any other comments:
The information I have given is correct to the best of my knowledge, and I have not withheld any medical information. I will inform the aesthetician before treatment of any changes (for example, in medications).
*
Submit
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