Infrared Detox Sauna Blanket Intake Form
This form is to be completed by all new clients. Once completed, the information is valid for 90 days. Every 90 days, a new form will need to be completed. When entering information, please make sure to be honest. The facilitator can best assist you if the answers to each question is truthful.
Is this your first time using the sauna blanket with Artistry Glam Esthetics
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Yes
No
Are you currently taking any medications?
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Yes
No
Are you over the age of 60?
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Yes
No
Do you have hyper/hypotension, CHF, or impaired coronary circulation?
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Yes
No
Are you pregnant?
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Yes
No
Have you consumed alcohol in the last 24hrs?
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Yes
No
Have you been diagnosed with multiple sclerosis?
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Yes
No
Have you had an organ removed?
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Yes
No
Do you take medication for seizures?
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Yes
No
Have you been diagnosed with a central nervous system tumor?
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Yes
No
Have you been diagnosed with diabetes with neuropathy?
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Yes
No
Have you been diagnosed with hemophiliac or are you prone to bleeding?
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Yes
No
Do you have a fever?
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Yes
No
Do you have heat sensitivity?
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Yes
No
Do you have a recent joint injury?
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Yes
No
Do you have a joint that is chronically hot or swollen?
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Yes
No
Do you have any implants?
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Yes
No
Do you have a pacemaker/defibrillator?
*
Yes
No
I
your name
certify that I HAVE NOT BEEN DIAGNOSED WITH ANY CONTRAINDICATIONS FOR AN IONIC FOOT BATH. If yes to any of these questions withdraws me from services.THIS TREATMENT IS NOT MEANT TO DIAGNOSE, TREAT OR CURE ANY DISEASE!
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