CLIENT CONSULTATION INFORMATION
SLIMMING
Name
First Name
Last Name
Email
example@example.com
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Height
Weight
Gender
Occupation
Are you pregnant?
Please Select
Yes
No
Are you on your period?
Please Select
Yes
No
Do you have gallbladder problems?
Please Select
Yes
No
Do you have thyroid problems?
Please Select
Yes
No
Do you suffer from constipation?
Please Select
Yes
No
Do you have the following eating disorders: Bulimia or Anorexia? Or frequent dieting?
Please Select
Yes
No
Do you suffer from epilepsy?
Please Select
Yes
No
Do you have hypertention?
Please Select
Yes
No
Do you have any tumors?
Please Select
Yes
No
Do you have any unhealed wounds after an operation?
Please Select
Yes
No
Do you suffer from acute inflammation?
Please Select
Yes
No
Do you have kidney disease?
Please Select
Yes
No
Do you have any metal implants? (Stents, Plates, Staples, etc)
Please Select
Yes
No
Do you have any plastic or silicone implants?
Please Select
Yes
No
Do you have the copper T as birth control?
Please Select
Yes
No
Do you have genetic hypersensitivity?
Please Select
Yes
No
Have you done Botox before?
Please Select
Yes
No
Do you have diabetes or hepatitis?
Please Select
Yes
No
Do you have an allergy to radio frequency?
Please Select
Yes
No
Do you have cancer?
Please Select
Yes
No
Do you use anticoagulant medicine? ( Prevent blood clots)
Please Select
Yes
No
Are you breastfeeding?
Please Select
Yes
No
Do you have cerebrovascular disease?
Please Select
Yes
No
Do you have diabetes or hepatitis?
Please Select
Yes
No
Any other allergies?
Please Select
Yes
No
Do you have any skin conditions?
Please Select
Yes
No
Are you on hormone treatment?
Please Select
Yes
No
Did you have any surgeries?
Please Select
Yes
No
Please select treatment option:
Please Select
Cryo - Fat Freeze
Cavitation
Vela Shape
Radio Frequency
EMS Treatment
Ozone
Vaginal thightening
Treatment Plan
Do you permit Lavida Slimming Studio to use your photos for marketing purposes and to post on social media?
Please Select
Yes
No
Habit Questionnaire?
1. How long have you been struggling with your weight?
2.How often do you eat sweets?
3. How often do you eat chips and cookies?
4. How often do you eat takeaways?
5. How often do you eat potatoes, pasta and bread?
6. How many liters of water do you drink per day?
7. How much is your alcohol intake?
7. How many cups of coffee do you drink?
8. How much soda drinks or fruit juices do you drink?
9. How many times per day do you eat?
10. Do you smoke?
11. Do you eat after 7 pm? And what time do you goto bed?
12. How many times a week do you exercise and what exercise?
13. What weight loss programs or treatments have you tried before?
14. What is your weight loss/contouring/shaping goal?
14. Is there any other information you feel is important to declare?
14. How did you hear about us?
Signature
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