T-SHAPE 2 Consultation Form

T-SHAPE2
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address
Contact Number
Email Address
example@example.com
LIFESTYLE QUESTIONS:
Profession
Work Environment

Mostly sitting at a deskMostly standing/walking aroundOther (please specify below)
Please Specify
Do you smoke
Do you consume alcohol?
Are you on any current medications If so please list the medications below
Are you pregnant or trying to get pregnant?

YesNoType option 4
Are you lactating?

NoYesType option 4
Have you undergone any recent medical changes minor or major Provide any details relevant
Please click all below that apply as a current or previous condition:

Pregnancy/LactatingMetal or mesh implants within the treatment areaActive implanted devices (pacemaker, urethral stimulator or internal defibrillatorCardiovascular disordersHypotension or HypertensionHypertenstionVaricose veins in desired treatment areaThrombophlebitisDilated capillariesActive cancer or cancer treatment in past 5 years (need doctor clearance)Current outbreak of HivesLiver/kidney DisordersDiabetes Type 1 and 2Keloid scar formationGlandular swellingSensitivity to light or consuming photosensitive medicationsVitiligoLupusAccutane or acne medicationSkin diseases or abnormal wound healingSurgery in the treatment area in the last 3 monthsFillers received within the last 4 weeks in desired treatment areaBotox within the past 2 weeks in desired treatment areaOpen LesionsAnticoagulant TherapyImplant ContraceptiveSubcutaneous Hormone Pellets (HRT)PDO Threads in the treatment area within the last 4 monthsUndiagnosed LumpsActive herpesType option 4
Please mention any conditions not listed above which may affect your skinbody during treatment
What areas of your body are you looking to improve with T-Shape 2?
What are your main goals for this treatment?

Fat reductionSkin tighteningCellulite reduction
3 How much water do you drink per day
4 What does your typical diet look like Are you following any specific eating patterns
How many times per week do you exercise, on average?

1-2x/wk3-4x/wk4 or more times per weekI do not exercise currentlyType option 2Type option 3Type option 4
6 Have you noticed changes in your skins elasticity or firmness If yes please explain
7 Do you have any concerns related to cellulite or uneven skin texture Are there areas of your body where fat seems resistant to diet and exercise
Do you have a special event or deadline that you are preparing for with this treatment?
9 How do you currently feel in your body and are there any changes you believe would help boost your confidence
10 Have you received any invasive treatments or undergone surgery within the last 6 months If so please write them below Examples include Botox Fillers Liposuction etc
If so, please write them below. (Examples include: Botox, Fillers, Liposuction, etc
Additional Notes
Client Signature

Clear
Technician Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

T-SHAPE2

LIFESTYLE QUESTIONS: