CLIENT INTAKE

CLIENT INFORMATION
DATE

MonthDayYear
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

FRUITSVEGATABLESRED MEATWHITE MEATSEAFOODSWEETSBREADSRICEFAST FOODCARBOHYDRATES
DAILY BEVERAGE

WATERSODASWEET TEACOFFEEJUICEALCOHOLOTHER
STRESS
HABITS

EXERCISECIGARETTESVAPERECREATIONAL DRUGSALCOHOL
BODY SLIMPLICITY
I consent to photos and measurements being taken and kept in my file.
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I agree to allow Body Simplicity, LLC to use my photos for marketing purposes on Social Media and Websites.
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DO YOU HAVE A CRONIC MEDICAL CONDITION?

YESNO
IF SO PLEASE INDICATE
HAVE YOU HAD ANY SURGERIES?

YESNO
PLEASE LIST
DO YOU HAVE ALLERGIES TO THE FOLLOWING?

LATEXMEDICATIONSSUPPLEMENTSESSENTIAL OILSHERBSCLAYSOTHER
MEDICATIONS
HERBAL SUPPLEMENTS
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? MARK ALL THAT APPLY

EPILEPSYINFECTIONSSKIN DISEASELOSS OF SENSATION (SKIN OR OTHERWIISE)HERPESAUTOIMMUNE DISEASEHEARING AIDSANEMIASICKLE CELL ANEAMIATHROMBOSIS/ PHLEBITISPACEMAKERMETAL IMPLANT DEVICESHORMONE PELLETSDIABETES TYPE I OR IITUMORSCANCER IN THE LAST 5 YEARSCHEMOTHERAPYRADIATIONTHYROID DISEASEHIGH BLOOD PRESSURECARDIOVASCULAR DISEASEVARICOSE VEINSGALL BLADDER REMOVALHISTROY OF GALLSTONESKIDNEY PROBLEMS/ DISEASELIVER PROBLEMS/ DISEASECOLON PROBLEMS/ DISEASEPREGNANT OR NURSINGNECK/ BACK PROBLEMSRECENT SURGERIESOther
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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CLIENT INFORMATION

DAILY INTAKE

BODY SLIMPLICITY