Cheshire Lasers Powersculpt and Powerform Treatment Consultation Form

Cheshire Lasers Powersculpt and Powerform Treatment Consultation Form
Full Name *

First Name Last Name
Date of Birth *

Month Day 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 able to phone you should we need to discuss your appointment? *

Yes No
Are we able to email you about your appointment? *

Yes No
Are you happy for us to text you about your appointment? *

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? *

Yes No
Is there any possibility of pregnancy or are you breast feeding? *

Yes No
Do you have any metal implants or screws, silicone implants or contraceptive devices near the area treated. *

Yes No
Do you have a Heart Condition or a Pacemaker / Defibrillator. *

Yes No
Have you had any Mesh surgery in the pelvic area or anywhere else? *

Yes No
Lifestyle & Medical History – please tick any that apply to you. *

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
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 Peel Botox Injectable Fillers Previous laser or IPL Treatment Silhouette Soft Threads in the last 10 weeks None of these
How often do you exercise? *

Never A few times a month Once a week Twice to Three times a week Four times a week or more
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?

Yes No
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? *

Yes No
Does/ will your treatment help you in any other way? *

Yes No
Do you worry about your appearance *

Yes No
Do you suffer from anxiety symptoms or low mood or any other mental health problems? *

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 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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