Beautiful Body Contouring

Beautiful body ContouringNew Client HistoryName:_____Date:_____Address:_____ Birth Date:_____Sex: M FCity:_____State_____Zip Code:_____Cell Phone:_____Home Phone:_____Work Phone:_____Email:_____Occupation_____How did you hear about us?_____What is your main area(s) of focus/your problem area(s)_____Medical HistoryDo you have any chronic medical conditions which we should know about? Yes NoIf so, please list:_____Do you have any allergies to latex, medications, herbal or natural supplements? Yes NoIf so, please list:_____Do you have, or have you had, any changes in medical history recently? Yes NoExplain:_____Do you have Hearing aids, Pacemaker or Hormone Pellets (where) or metal/ medical devices implanted?

Medical History Do you have any chronic medical conditions which we should know about? Yes No If so, please list:_____ Do you have any allergies to latex, medications, herbal or natural supplements? Yes No

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