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Client Heavy Medical & Treatment Intake Form

1. Personal Information

Date of Birth
Day
Month
Year

2. General Health

Do you have any chronic medical conditions?
yes
no
Do you currently take any prescribed medications?
yes
no
Do you take blood thinners (e.g., Aspirin, Warfarin, Apixaban, others)?
yes
no
Do you take anti-inflammatory medications (NSAIDs)?
yes
no
Do you take steroids or immunosuppressive medication?
yes
no
Do you currently take antibiotics?
yes
no
Do you have any diagnosed blood, clotting, or bleeding disorders?
yes
no
Do you have any autoimmune conditions?
yes
no
Do you have diabetes?
yes
no
Do you have thyroid conditions?
yes
no
Do you have any heart or circulation issues?
yes
no
Have you ever fainted during medical procedures?
yes
no
Do you take any herbs?
yes
no

3. Allergies & Sensitivities

4. Skin & Treatment History

Do you have psoriasis or eczema in the treated area?
yes
no
Do you have a history of keloids or abnormal scarring?
yes
no
Have you had aesthetic treatments in the last 4 weeks?
yes
no
Have you had PRP/PRF/injections in the past? Any complications?
yes
no
Do you currently have dental infections or recent dental procedures?
yes
no
Do you smoke?
yes
no
Do you consume alcohol regularly?
yes
no

5. Contraindications

Are you pregnant or breastfeeding?
yes
no
Do you have active cold sores or viral infections?
yes
no
Do you have cancer or ongoing oncology treatment?
yes
no
Do you have hepatitis or HIV?
yes
no
Any recent surgeries (last 6 months)?
yes
no

6. Consent & Understanding

  • I confirm that I have provided accurate medical information.

  • I understand the nature, risks, and benefits of the selected treatment.

  • I consent to a medical assessment prior to treatment.

  • I agree to follow all pre- and post-treatment instructions.

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