Surveypoint

Q1

State/Province

Q2

Zip/Postal Code

Q3

Phone *

Q4

Gender

Q5

Emergency Contact Name

Q6

Phone

Q7

Email*

Q8

How would you like to receive your updates, appointment confirmations, specials and discounts email notification?

Q9

Are you a referral?

Q10

Enter Referrals Name? *

Q11

Do you have any chronic medical conditions that we should know about?

Yes

No

Q12

If yes, please list:

Q13

Are you currently taking any medications?

Yes

No

Q14

If yes, please explain:

Q15

Have you had any plastic surgery?

Yes

No

Q16

Do you have type 1 or type 2 diabetes?

Yes

No

Q17

Do you have any known kidney or liver disorders?

Yes

No

Q18

If yes, are you currently on chemotherapy?

Yes

No

Q19

Have you had cancer in the past 12 months?

Yes

No

Q20

Do you have any thyroid problems?

Yes

No

Q21

Do you have high blood pressure?

Yes

No

Q22

Do you have any cardiovascular conditions?

Yes

No

Q23

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?

Yes

No

Q24

Weight

Q25

Height

Q26

Waist

Q27

Hip

Q28

Right Thigh

Q29

Left Thigh

Q30

Right Bicep

Q31

Left Bicep

Q32

What concerns would you like addressed today?

Q33

Do you want to lose body fat?

Yes

No

Q34

If yes, from what area:

Q35

Do you want to tighten skin on your body

Yes

No

Q36

Do you want to reduce cellulite?

Yes

No

Q37

Please list your regular exercise habits:

Q38

Please describe your current dietary habits:

Q39

How many ounces of water do you drink daily?

Q40

(Female clients) Are you currently pregnant or nursing?

Yes

No

Q41

When was the first day of your last menstrual cycle?

Q42

Name Printed

Q43

Signature

Q44

Fat Cavitation Client Intake Form -Form Fill

State/Province

Zip/Postal Code

Phone *

Gender

Emergency Contact Name

Phone

Email*

How would you like to receive your updates, appointment confirmations, specials and discounts email notification?

Are you a referral?

Enter Referrals Name? *

Do you have any chronic medical conditions that we should know about?

If yes, please list:

Are you currently taking any medications?

If yes, please explain:

Have you had any plastic surgery?

Do you have type 1 or type 2 diabetes?

Do you have any known kidney or liver disorders?

If yes, are you currently on chemotherapy?

Have you had cancer in the past 12 months?

Do you have any thyroid problems?

Do you have high blood pressure?

Do you have any cardiovascular conditions?

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?

Weight

Height

Waist

Hip

Right Thigh

Left Thigh

Right Bicep

Left Bicep

What concerns would you like addressed today?

Do you want to lose body fat?

If yes, from what area:

Do you want to tighten skin on your body

Do you want to reduce cellulite?

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?

(Female clients) Are you currently pregnant or nursing?

When was the first day of your last menstrual cycle?

Name Printed

Signature

Date