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Body Contouring Patient Form
Body Contouring Patient Form
drnovikovaadmin
2020-07-09T12:42:12+00:00
Body Contouring Patient Information
Body Contouring Patient Information
Surname
*
Name
*
Email
*
Date Of Birth
*
Phone
*
Home Address
*
Details of Current Employment
How did you hear about us?
Height
*
Weight
*
What area of the body would you like to address?
*
What are your reasons for Body Contouring?
What are your expectations from Body Contouring?
Do you have cellulite?
Yes
No
If yes, where is it located?
If yes, where is it located?
Do you have any loose skin?
Yes
No
What medication are you taking? If any.
What supplements are you taking? If any.
Have you had medical illness in the past? If yes, please describe and provide details of treatment if any.
Please specify any chronic diseases you may have?
What allergies do you have? If any.
What surgeries have you had in the past including cosmetic surgery? Please state date of surgeries if applicable.
Please specify and describe if you have any significant family history?
Do you have any metal implants?
Yes
No
Do you have a pacemaker?
Yes
No
Please describe your exercise routine- duration, weekly frequency, intensity and type
Please describe your diet-breakfast, lunch, dinner, snack, drinks
Do you drink alcohol?
Yes
No
If yes, how many per week?
If yes, how many per day?
Do you smoke cigarettes?
Yes
No
If you have tried to lose weight in the past, please describe your approach and methods?
What obstacles do your foresee in reaching your ideal well-being goals (body image, health, wealth)?
If you are human, leave this field blank.
Submit
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