CLIENT INFORMATION
DATE
/
Month
/
Day
Year
Date
NAME
CITY
ADDRESS
STATE
ZIP
DOB
EMAIL
example@example.com
OCCUPATION
ETHNICITY
CELL
WORK
HOME
HEIGHT
WEIGHT
How did you hear about us?
What area/s are you mostly concerned about?
I (print) give the technician/s at Body Slimplicity permission to consult and evaluate me to determine whether am a candidate for non surgical body treatment
DAILY INTAKE
DAILY FOOD
FRUITS
VEGATABLES
RED MEAT
WHITE MEAT
SEAFOOD
SWEETS
BREADS
RICE
FAST FOOD
CARBOHYDRATES
DAILY BEVERAGE
WATER
SODA
SWEET TEA
COFFEE
JUICE
ALCOHOL
OTHER
STRESS
Please Select
MILD
MODERATE
SEVERE
HABITS
EXERCISE
CIGARETTES
VAPE
RECREATIONAL DRUGS
ALCOHOL
BODY SLIMPLICITY
I consent to photos and measurements being taken and kept in my file.
Signature
I agree to allow Body Simplicity, LLC to use my photos for marketing purposes on Social Media and Websites.
Signature
DO YOU HAVE A CRONIC MEDICAL CONDITION?
YES
NO
IF SO PLEASE INDICATE
HAVE YOU HAD ANY SURGERIES?
YES
NO
PLEASE LIST
DO YOU HAVE ALLERGIES TO THE FOLLOWING?
LATEX
MEDICATIONS
SUPPLEMENTS
ESSENTIAL OILS
HERBS
CLAYS
OTHER
MEDICATIONS
HERBAL SUPPLEMENTS
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? MARK ALL THAT APPLY
EPILEPSY
INFECTIONS
SKIN DISEASE
LOSS OF SENSATION (SKIN OR OTHERWIISE)
HERPES
AUTOIMMUNE DISEASE
HEARING AIDS
ANEMIA
SICKLE CELL ANEAMIA
THROMBOSIS/ PHLEBITIS
PACEMAKER
METAL IMPLANT DEVICES
HORMONE PELLETS
DIABETES TYPE I OR II
TUMORS
CANCER IN THE LAST 5 YEARS
CHEMOTHERAPY
RADIATION
THYROID DISEASE
HIGH BLOOD PRESSURE
CARDIOVASCULAR DISEASE
VARICOSE VEINS
GALL BLADDER REMOVAL
HISTROY OF GALLSTONES
KIDNEY PROBLEMS/ DISEASE
LIVER PROBLEMS/ DISEASE
COLON PROBLEMS/ DISEASE
PREGNANT OR NURSING
NECK/ BACK PROBLEMS
RECENT SURGERIES
Other
These forms have been completed truthfully to the best of my ability. If fail to indicate history. release liability from Body Slimplicity and/ or its agents for any post treatment symptoms or side effects.
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