Client Medical Consultation / Treatment Record

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Transcription:

Client Medical Consultation / Treatment Record Title (Mr/Mrs/Ms/Miss): Client Name: Address: Physician Name & Surgery: Physician Contact No: Tel Home: Tel Work: Tel Mobile: E-mail Address: Postcode: Age: Gender (Male/Female): How did you hear about us?: Epilepsy Urine infection Diabetes Cancer Medical oedema HRT (Hormone replacement therapy) Are you currently suffering or have ever suffered from any of the following: Contraceptive Pill / Coil / Other Any Kidney problems or issues Auto immune disease Currently pregnant Gastric ulcers Any form of infection, fever or disease Cardio vascular conditions Regular antibiotics/medications taken Any condition already being treated by a practitioner: (Thrombosis, phlebitis, hypotension, hypertension, heart conditions/disease) If yes, please list. Use of recreational drugs or alcohol: List ALL medication / regular supplements that you are currently taking: F0-7 A Page of 5

Client Medical Consultation / Treatment Record Thyroid problems Any metal pins/plates/cosmetic implants Dermatitis or other skin issues Do you have any of the following: Muscular/skeletal problems Digestive problems Circulation problems Gynaecological problems Nervous system Immune system Back aches / Pain / Stiff joints / Headaches Constipation / Bloating / Liver / Gall bladder / Stomach Heart / Blood pressure / Fluid retention / Varicose veins Irregular periods / PMT / Menopause Migraine / Tension / Stress / Depression Prone to infection / Sore throats / Colds / Chest / Sinuses Lifestyle questions: Last period dates: Job description: Do you eat regular meals? How many per day? Do you eat in a hurry? Do you exercise? PLEASE TICK: Occasionally Irregularly Regularly Please list types of exercise: Do you take vitamin supplements? Do you suffer allergies? If yes, please list If yes, please list How would you mark your current stress level? (-0, where is low, 0 is high): Do you smoke? Do you drink alcohol? If yes, how many per day? If yes, approximate units per week?.. Date of last visit to the Doctor: Please list any recent Operations / Fractures / Scars / Localised swelling: (Within months for fractures and year for operations) F0-7 A Page of 5

Client Treatment Consent Form I duly authorise the practitioners of. to perform the ilipo procedure for the purpose of spot fat reduction / improving the appearance of cellulite. I am aware that clinical results may vary depending on individual factors, including medical history, client compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained. I understand the treatment involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course the outstanding treatment value is non refundable. The course cost is $ (Client initials).. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I understand that it is my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the course of ilipo treatment sessions and I confirm that should this occur I shall advise the practitioner of any changes. I consent to the taking of photographs and authorise their anonymous use for the purposes of medical audit, education and promotion. Delete if preferred. I certify that I have been given the opportunity to ask questions, any questions have been answered to my satisfaction and that I have fully read and understood the contents of this consent form. Client Name (Printed):.. Client Signature: Date:.. Practitioner Signature:.. F0-7 A Page of 5

Client Pre-Treatment Measurements Client Name: Date: Area Treated: MEASUREMENT DETAILS POINT LOCATION.... MEASUREMENT (Right/Central/Left) Delete as necessary Height: Weight: BF%: MEASUREMENT (Right/Central/Left) Delete as necessary Treatment Location: Mark Lymphatic Probe placement with crosses Mark pad placement with shaded area Notes: F0-7 A Page of 5

F0-7 A Page 5 of 5 Client Treatment Record TREATMENT DATE WEIGHT BF% MEASUREMENTS LOSS BEFORE AFTER 5 6 7 8

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