Infrared Sauna Intake Form

Is this your first time using the sauna with Clio Therapeutics*

YesNo

Are you currently taking any medications?*

YesNo

Are you over the age of 60?*

YesNo

Do you have hyper/hypotension, CHF, or impaired coronary circulation?*

YesNo

Are you pregnant?*

YesNo

Have you consumed alcohol in the last 24hrs?*

YesNo

Have you been diagnosed with multiple sclerosis?*

YesNo

Have you had an organ removed?*

YesNo

Do you take medication for seizures?*

YesNo

Have you been diagnosed with a central nervous system tumor?*

YesNo

Have you been diagnosed with diabetes with neuropathy?*

YesNo

Have you been diagnosed with hemophiliac or are you prone to bleeding?*

YesNo

Do you have a fever?*

YesNo

Do you have heat sensitivity?*

YesNo

Do you have a recent joint injury?*

YesNo

Do you have a joint that is chronically hot or swollen?*

YesNo

Do you have any implants?*

YesNo

Do you have a pacemaker/defibrillator?*

YesNo

I your name understand that these sessions are for the purpose of relaxation and not intended to treat any condition or disease or to take place of medical care or medication. I clearly confirm that I do not have any contraindications to use the Infrared Sauna. By signing I agree to release Clio Therapeutics and any Clio Therapeutics, LLC representatives from any liability in connection with the use of the sauna and our facilities if any of my health information above is false or inaccurately reported. I agree to step out of the sauna immediately if I experience dizziness or get sleepy.
*In the rare event of pain and/or discomfort please exit the sauna and forfeit any use of our sauna until you get a release signed from a physician.*