Pressotherapy Consultation Form Cryo Solihull Name(Required) First Last Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)GP Details(Required) Occupation(Required) Lifestyle(Required) Very Active Sedentary Average How often do you exercise?(Required) Stress Levels (Scale 1 - Great 10 Very High)(Required) How many hours of sleep do you get a night?(Required) How much water do you drink per day? Pints/Glasses/Litres?(Required) Do you drink alcohol? Answer yes or no / If yes how many units a week(Required) Do you Smoke?(Required) Yes No Do you follow a healthy diet? Yes No Sometimes Do you follow an exclusion diet? i.e. gluten free/diary free/vegan/vegetarian etc Do you take vitamin and mineral supplements?(Required) Yes No Are you under medical supervision at present?(Required) No Doctor Hospital Dermatologist Have you ever undergone plastic surgery? If yes please give details Please state the main reason for your treatment? Detox/Muscle aches/Post Surgery etc(Required) Are you pregnant or could be pregnant? Please note we can not carry out this treatment due to insurance(Required) Yes No Do you have any of the following?(Required) New or suspected deep vein thrombosis or thrombophlebitis Any Pain or numbness anywhere in the body Severe arteriosclerosis or "ischemic"vascular diseases Gangrene Dermatitis Untreated or infected wounds Severe inflammation of the skin Recent skin grafts Do you have any heart conditions? Do you suffer from circulatory problems in your legs or arms? Have you had any operations with the last 3 years? Do you have any electronic implants in your body? Do you have any metal objets in your body? Are you under any medical treatments at this present time? Do you have any allergies - If yes please provide further details Are you taking HRT? Are you taking any medication - if yes please provide further details Do you suffer any respiratory problems? Do you have epilepsy? Do you have diabetes or any other metabolic illness? Do you have or had any type of cancer? Do you have diabetes? Do you have any thyroid conditions? Do you have any kidney problems? Do you have any varicose veins? Are you in menopause pre/post? I have none of the above If yes to any of the above please provide further information. I have completed this form to the best of my ability and will let my therapist know if any of the information above changes. I understand that any holistic therapy is not intended to diagnose or treat any medical conditions. If you have any of the following conditions the treatment will not be carried out as they will not be insured. Thrombosis/Embolus/Phelbitis/Unstable heart conditions/Shingles/Pregnancy/Fever/Cancer/Metal/Electronic implants* Please provide any further details that may help your therapist Please note our cancellation policy is 48 hours - less than 48 hours full cost of the appointment will be charged.(Required) I agree to this policy. And give consent to Cryo Solihull to store my details under GPDR compliance.Date MM slash DD slash YYYY Δ
