New Client Medical History Form

Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Birth Date*

DayMonthYear
E-mail*
Mobile Phone Number*
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 *

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

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

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

YesNo
Do you have type 1 or 2 Diabetes?

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

YesNoIf Yes, are you currently going through chemotherapy
List all current Medications including Vitamins*
Please specify including date
Do you have high blood pressure or cardiovascular condition? *

YesNo
Do you have a Thyroid Problem? *

YesNo
Have you had any surgeries in the last 12 months?

YesNo
Females, are you currently pregnant or nursing?

YesNo
Have you ever been diagnosed with any of the following?

AsthmaDiabetesCancerHepatitisEpilepsyHIV/AIDsTuberculosisMultiple SclerosisPolioLeukaemiaSARS/Bird FluHeart DiseaseHigh Blood PressureHigh CholesterolDepressionAnxietyPTSDIBSAlzheimer'sAutoimmune disease
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.
Please sign your initials that you have received and understand our policy:*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
We promise not to bombard you with spam mail :) Would you like to receive our newsletter emails?*

YesNo
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