Enhanced B Bar
Full Name:
Date:
Address:
DOB:
Gender at birth: MF
City:
State:
Zip Code:
Phone:
2 ndary Phone:
Email:
Occupation:
How did you hear about us? Please name person referred by, if applies:
Personal referralSocial MediaWeb searchWebsiteOther
Height:
Weight:
Ethnicity:
What area(s) would you like us to focus on?
Do you have any chronic medical conditions which we should know about?
YesNo
If so, please list:
Do you have any allergies to latex, medications, herbal or natural supplements?
Do you have/had any changes in your medical condition recently?
If so, please explain:
Do you have hearing aids, a pacemaker, hormone pellets or metal/medical devices implanted?
If so, please indicate what and where on your body:
Do you have Diabetes? Type 1 or 2?
List all current medications including vitamins:
Do you have/had cancer in the last 12 months?
If so, are you currently on chemotherapy?
Do you have a thyroid problem?
Do you have high blood pressure or any cardiovascular conditions?
Are you currently pregnant or nursing?
Check all medical conditions which apply to you:
Neck/back problemsHistory of gallstonesColon problemsImplants of any kindTumorsAutoimmune diseaseEpilepsyGallbladder removedHistory of liver problemsProtruding/distendedbelly InfectionsSkin Disease Thrombosis/ phlebitisAbnormal skin sensitivities/sensationsOther
Other:
Are you currently dieting?
Indicate typical daily food/fluid intake. How much/how often? :
Water: Coffee: Soda/Carbonated Bev: Alcohol: Fast foods: Tobacco use: Recreational Drugs:
Current stress Level:
LowModerateHigh
I, (print name) , consent to allow Enhanced Beauty Bar, Body Sculpting and Aesthetics staff members to consult with and evaluate me in order to determine if I am a good candidate for the non-surgical/non-invasive body contouring program. I understand and consent to body measurements and photography/video being taken and archived. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities.
CLIENT SIGNATURE
Date
