New Client Medical History Form

Full Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

City

Post Code

Birth Date

DayMonthYear

E-mail

Mobile Phone Number

Format: (00) 00 000 000.

How did you hear about us?

If you were referred, who can we thank for referring you?

Full name please

Occupation

Emergency Contact

Name & contact number

Allergies

Medications

Prescribed & supplements/herbs

Do you have any chronic medical conditions which we should know *

Do you have any allergies to latex, medications, herbal or natural products? *

Do you have, or have you had, any changes in medical history recently? *

Do you have any hearing aids, a pacemaker, hormone pallets, or medical devices implanted? *

Do you have type 1 or 2 Diabetes?

Do you have or have you had Cancer in the last 12 months?

List all current Medications including Vitamins

Please specify including date

Do you have high blood pressure or cardiovascular condition? *

Do you have a Thyroid Problem? *

Have you had any surgeries in the last 12 months?

Females, are you currently pregnant or nursing?

Have you ever been diagnosed with any of the following?

What are your main area(s) of focus/your problem area(s?) *

11. What are the physical duties required of your occupation?

I consent to allow C to consult with & evaluate me in order to determine if I am a good candidate for the Non-surgical Body Contouring Program. I understand that photographs and measurements will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge/abilities.

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