CLIENT INTAKE

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
HABITS

EXERCISE CIGARETTES VAPE RECREATIONAL DRUGS ALCOHOL
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?

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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CLIENT INFORMATION

DAILY INTAKE

BODY SLIMPLICITY