Pre Consultation Questionnaire
The purpose of this questionnaire is to provide me with enough information to provide you with a package which will address your body goals. It also establishes if you are a suitable candidate for these treatments and will enable me to offer alternative options where it may be possible. You will therefore have to provide me with accurate information as well as be completely honest regarding your body goals and expectations. Your information will in no way be shared with any third parties and is purely for the reason stated above.
Date of Birth
Please enter a valid phone number.
Your Body Goals
What is your main area of concern?
Waist (love handles)
Which of these would you like to achieve through the LipoGym programme?
Lose body fat
Improve overall body health
Tone and firm problem areas
How quickly do you expect to see results?
Are you able to commit to 2-4 sessions per week in order to achieve the best results? (The amount of sessions as well as frequency will depend on the type of treatment recommended)
Your Current Lifestyle
What is your current weight?
What is your goal weight?
What is your waist circumference (measure across belly button) in cm's
How tall are you?
Do you currently exercise?
If yes, please describe your current exercise habits.
How would you describe your current eating habits?
Are you currently taking dietary supplements? (USN, Herbalife etc)
If you are currently taking supplements, which brand are you using and what products? (Shakes, Fat Burners, CLA's etc)
How many glasses of water do you drink per day?
How well do you sleep at night?
Tick to answer "YES or NO" if you currently have or had any of the following conditions.
Currently pregnant or breastfeeding
Cardiac or Vascular Condition
Pacemaker or other electronic devices
Recent abdominal surgery
History of Internal Bleeding
Abnormal Blood Pressure
Taking any Anti Coagulants
Liver or Kidney Disease
Any Infectious Disease
Implants (any material)
Do you have any other chronic medical conditions, not listed above, I should know about?
If yes, please specify.
Are you currently taking any medication? (Prescription or OTC)
If yes, please specify.
Please list allergies, if any.
The treatments offered as part of the LipoGym Body Sculpting packages are all scientifically sound and well researched. While all clients will see and feel a measurable difference in the areas treated, it is important to note that these results will differ from client to client. We also recommend that clients be at least within 15kgs of their goal weight for the best results. Body sculpting is NOT a weightloss program. Also important to note that a course of treatments will deliver better results, depending on the protocol recommended and that these results will be enhanced by making positive lifestyle and dietary changes. Body sculpting is a fat loss and toning solution. Diet and exercise are needed for weight loss. While immediate results may be experienced after some of the protocols, you are reminded that the treatment is the START of the process. Your body still needs time to remove fat through natural metabolic processes, which cannot happen faster than naturally possible. There is NO INSTANT cure or treatment!
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