Strawberry Laser Medical Questionnaire

Client Name:

Date:

Referral:

Please list any / all medications that you are currently taking in hte space provided below. It's up to the doctor's discretion if he / she feels that you are able to receive a strawberry laser lipo treatment course.

Current Medications:

CHIEF COMPLAINT/ Areas of target:

Have you ever experienced any of the following specific conditions?

Answer Yes or No where appropriate and give details

Epilepsy:

YesNo

If YES explain/ additional notes:

Diabetes:

YesNo

If YES explain/ additional notes:

Pacemakers:

YesNo

If YES explain/ additional notes:

Cancer:

YesNo

If YES explain/ additional notes:

Any liver problems:

YesNo

If YES explain/ additional notes:

Any kidney problems:

YesNo

If YES explain/ additional notes:

Auto immune disease:

YesNo

If YES explain/ additional notes:

Currently pregnant or breastfeeding:

YesNo

If YES explain/ additional notes:

Have you ever experienced Hyper/Hypo-pigmentation:

YesNo

If YES explain/ additional notes:

Any form of infection fever or disease:

YesNo

If YES explain/ additional notes:

Photosensitivity:

YesNo

If YES explain/ additional notes:

Keloid Scaring:

YesNo

If YES explain/ additional notes:

Cardio vascular conditions:

YesNo

If YES explain/ additional notes:

Any condition currently treated by a medical practitioner:

YesNo

If YES explain/ additional notes:

Any tattoos in the proposed areas of treatment:

YesNo

If YES explain/ additional notes:

Thyroid problems:

YesNo

If YES explain/ additional notes:

Any metal pins or plates:

YesNo

If YES explain/ additional notes:

Muscular / skeletal problems:

YesNo

If YES explain/ additional notes:

Digestive Problems:

YesNo

If YES explain/ additional notes:

Circulation Problems:

YesNo

If YES explain/ additional notes:

Gynecological problems:

YesNo

If YES explain/ additional notes:

Immune System:

YesNo

If YES explain/ additional notes:

Do you have regular periods:

YesNo

If NO explain/ additional notes:

Do you work at a computer:

YesNo

Do you eat regular meals:

YesNo

If NO explain/ additional notes:

Do you eat in a hurry:

YesNo

Do you exercise:

YesNo

If NO explain/ additional notes:

Do you suffer from allergies:

YesNo

If YES explain/ additional notes:

How would you mark your current stress level:

Enter the Date of your last doctor appointment

MonthDayYear

Additional conditions not listed (please list below)

Print Name

First NameLast Name

Signature:

Date

MonthDayYear

Strawberry Laser Lipo Inch Loss

Lifestyle Questions