Pre Treatment Customer Questionnaire

If you have been directed to this page it’s because one of our consultants have spoken to you already and offered you a time and date for your appointment.

Please either complete the online form or download the pdf or word document. Once received if we have any questions we will be back in touch.

Download Form

Customer Form

Client Name*
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Occupation*
Practitioner Name*
Post Code*
Telephone No*
Your Email*
Todays Date*
MM slash DD slash YYYY
Address*
Health and Lifestyle
Contraindications
Liver/Kidney Disease*
- Yes
- No
Heart Conditions inc. Pacemaker*
- yes
- No
Silicosis or other Lung Conditions*
- yes
- No
Cancer (Radiotherapy/Chemotherapy)*
- Yes
- No
Reynaud’s Disease (or other vaso constrictive disorders)*
- Yes
- No
Physical Hypotonic*
- Yes
- No
Cardiovascular Disease*
- Yes
- No
Cerebral Disease*
- Yes
- No
Immune System Disease (i.e. AIDS or HIV)*
- Yes
- No
Immune System Disease (i.e. AIDS or HIV)*
- Yes
- No
Urticarial or other immune disorders*
- Yes
- No
Hypoproteinaemia*
- Yes
- No
Frostbite Intolerance*
- Yes
- No
Hernia or weak stomach muscle walls*
- Yes
- No
Severe diabetes*
- Yes
- No
Recent invasive surgery (in the last 12 months)*
- Yes
- No
Artificial Implants (bone, etc)*
- Yes
- No
Metal Plates or Joint Implants*
- Yes
- No
Sites of prior cosmetic surgery*
- Yes
- No
Pregnant or Breastfeeding*
- Yes
- No
Currently under the influence of drugs or alcohol*
- Yes
- No
Do you have any of the following?
Hyper or Hypotension*
- Yes
- No
Scarring history, fibrosis or seborrhoea*
- Yes
- No
Haemophilia or other clotting disorders*
- Yes
- No
Epilepsy*
- Yes
- No
Diabetes*
- Yes
- No
Thyroid Condition*
- Yes
- No
Hormonal Imbalances*
- Yes
- No
Other immune disorders not listed*
- Yes
- No
Received or donated organ transplants*
- Yes
- No
Psoriasis or eczema in treatment area*
- Yes
- No
Keloid/hypertrophic scar in the region*
- Yes
- No
High Cholesterol*
- Yes
- No
Thrombosis (past or present)*
- Yes
- No
Broken Bones*
- Yes
- No
Undiagnosed swelling or inflammation*
- Yes
- No
Bruising, cuts or abrasions (treatment area)*
- Yes
- No
Fever*
- Yes
- No
Menstruation*
- Yes
- No
Any other conditions not listed*
- Yes
- No
Do you have a pacemaker or any other electronic device fitted within your body?*
- Yes
- No
Do you have a copper coil fitted?*
- Yes
- No
If yes please list:*
If you have answered yes to any of the above, please give full details:*
Are you currently taking any medication?*
- Yes
- No
Do you exercise?*
- Yes
- No
How is your sleep pattern?*
- Good
- Average
- Poor
How is your diet?*
- Good
- Average
- Poor
Do you drink alcohol?*
- Yes
- No
Do you smoke?*
- Yes
- No
If yes, please list all medications*
No. of Hours Sleep per night:*
How much water do you drink per day?*
If yes, how many units per week?*
If yes, how many cigarettes per day?*
How often do you exercise per week?*
Have you ever had cryo body contouring or any fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.*
- Yes
- No
Are you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO*
- Yes
- No
By pressing submit, you agree that we can contact you via the supplied details. We promise to only use your details to contact you in relation to this specific enquiry. Our full Privacy Policy
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