hbspt.forms.create( portalId: "6347683", formId: "6032bec1-13ce-4034-8d57-a3e6df530d02" ); Customer Data form Pre Appointment. Client Name*Date of Birth* Date Format: DD dash MM dash YYYY Gender*MaleFemaleOccupation*Practitioner Name*Post Code*Telephone No*Your Email* Todays Date* Date Format: DD dash MM dash YYYY Address*Health and LifestyleContraindicationsLiver/Kidney Disease*YesNoHeart Conditions inc. Pacemaker*yesNoSilicosis or other Lung Conditions*yesNoCancer (Radiotherapy/Chemotherapy)*YesNoReynaud’s Disease (or other vaso constrictive disorders)*YesNoPhysical Hypotonic*YesNoCardiovascular Disease*YesNoCerebral Disease*YesNoImmune System Disease (i.e. AIDS or HIV)*YesNoImmune System Disease (i.e. AIDS or HIV)*YesNoUrticarial or other immune disorders*YesNoHypoproteinaemia*YesNoFrostbite Intolerance*YesNoHernia or weak stomach muscle walls*YesNoSevere diabetes*YesNoRecent invasive surgery (in the last 12 months)*YesNoArtificial Implants (bone, etc)*YesNoMetal Plates or Joint Implants*YesNoSites of prior cosmetic surgery*YesNoPregnant or Breastfeeding*YesNoCurrently under the influence of drugs or alcohol*YesNoDo you have any of the following?Hyper or Hypotension*YesNoScarring history, fibrosis or seborrhoea*YesNoHaemophilia or other clotting disorders*YesNoEpilepsy*YesNoDiabetes*YesNoThyroid Condition*YesNoHormonal Imbalances*YesNoOther immune disorders not listed*YesNoReceived or donated organ transplants*YesNoPsoriasis or eczema in treatment area*YesNoKeloid/hypertrophic scar in the region*YesNoHigh Cholesterol*YesNoThrombosis (past or present)*YesNoBroken Bones*YesNoUndiagnosed swelling or inflammation*YesNoBruising, cuts or abrasions (treatment area)*YesNoFever*YesNoMenstruation*YesNoAny other conditions not listed*YesNoIf yes please list:*If you have answered yes to any of the above, please give full details:*Are you currently taking any medication?*YesNoDo you exercise?*YesNoHow is your sleep pattern?* Good Average Poor How is your diet?* Good Average Poor Do you drink alcohol?*YesNoDo you smoke?*YesNoIf 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.*YesNoAre you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO*YesNoBy 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 PolicyCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
