getparamounthealth.com - Weight Loss Red Light Intake Form

Weight Loss Red Light Intake Form
PERSONAL INFORMATION
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Height
Occupation
Who may we thank you for referring you to our office?

Other
Name:
MEDICAL HISTORY

Do you or any family member have/had any of the following? Please select an "X" for you, and "F" for family

Rows	X	F
Liver Concerns
Depression
Heart Attack
Diabetes
Thyroid Disease
Gallbladder Disease
Kidney Disease
Stroke
Fatigue
Brain Fog
Hypoglycemia
Anemia
Cancer
High Blood Pressure
Intestine Problems
Shortness of Breath
High Cholesterol
Headache
Poor Sleep
Dizziness
Arthritis
Carpal Tunnel
Neuropathy/Nerve
Problems
Weight Gain
Back Pain
Neck Pain
Shoulder Pain
Knee Pain

Is there a certain time of day any of these problems are better or worse?
Are you taking any medications/supplements?
If yes, please list.
Are you pregnant?
How many children?
How many Pregnancies?
Are you breast feeding?
Any known allergies?
If yes, please list.

Main Concerns:

Rows	Concern
1
2
3
4

How long have you had this/these concerns?
What effect does this have on your body functions or quality of life?
What would be different or better without this/these concerns?
How have you addressed weight management in the past?

Other
How did the previous methods work for you?
What potential barriers do you foresee that would prevent the change you are looking for?
What outcome would you like to see for this to be a success for you?
Do you feel it possible to eliminate or prevent these potential barriers?
Please rate on a scale of 1-10 (1 being the lowest and 10 being the highest)
Energy Level

1

2

3

4

5

6

7

8

9

10

1 is lowest, 10 is highest
Quality of Sleep

1

2

3

4

5

6

7

8

9

10

1 is lowest, 10 is highest
How Important It Is For You To Resolve Your Health Concerns

1

2

3

4

5

6

7

8

9

10

1 is lowest, 10 is highest
What Is Your Level of Preparedness To Make Necessary Lifestyle Changes To Achieve Your Goals?

1

2

3

4

5

6

7

8

9

10

1 is lowest, 10 is highest
I AM INTERESTED IN

INFORMED CONSENT FOR DAHLIA

RED LIGHT THERAPY
This consent to treatment form explains the risks and benefits of the Dahlia Red Light

Therapy treatments. Patient understands the following:
1. Results vary greatly from person to person. No result is guaranteed.
2. Dahlia Red Light Therapy is a treatment intended to be implemented in conjunction with a modification in diet and lifestyle as part of a complete protocol. The recommended diet and lifestyle is a critical part of the program and are essential in achieving the maximum results.
3. Temporary hyperpigmentation/hypopigmentation (changes in skin color) on rare occasions may occur as a result of treatment.
4. Light therapy has no known contraindications. However, Dahlia does not recommend treatments for patients who are under the age of 18 (without parental consent), who are pregnant, or who have active skin or other cancers (active or within 1 year of remission).
By signing below, patient agrees that Paramount Health may perform the Dahlia Light procedure for the purpose of body contouring. Patient understands and accepts the risks listed above and agrees that all information on this form is true and correct to the best of patient’s knowledge.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: