First Name
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Last Name
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Email
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Mobile Number
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Date of birth
Street Address
Suburb
Emergency contact
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Emergency contact number
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Emergency contact relationship
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Medical History
Are you currently receiving any treatment from a doctor or specialist?
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Yes
No
If yes, please give details
Are you taking any medication, supplements or herbal remedies?
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Yes
No
If yes, please give details
Are you allergic to latex?
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Yes
No
DEVICE CONTRAINDICATIONS
GAMEREADY CRYO-COMPRESSION
Please indicate if you have suffered from any of the following conditions:
Raynaud's Disease
Local Limb ischemia
Cold Allergy
Open/Uncovered wounds or sores
Paroxysmal cold hemoglobinuria
No abdomen area can be treated if pregnant
Acute stages of inflammatory phlebitis in the affected region
History or current clinical signs suggestive of deep vein thrombosis or pulmonary embolus in the affected region (to be treated with this therapy)
Significant arteriosclerosis or other vascular ischemic disease in the affected region.
A condition in which increased venous or lymphatic return is not desired in the affected extremity (e.g., carcinoma).
Decompensated hypertonia in the affected region
Significant vascular impairment in the affected region (e.g., from prior frostbite, diabetes, arteriosclerosis or ischemia)
Local Limb ischemia
Hematological dyscrasias which affect thrombosis (e.g., paroxysmal cold hemoglobinuria, cryoglobulinemia, sickle-cell disease, serum cold agglutinins)
CELLUMA LED LIGHT THERAPY
Please indicate if you have suffered from any of the following conditions:
Pregnant or Breastfeeding
Epilepsy or history of seizures
Taking any steroid injections
Taking photosensitive drugs
NORMATEC SEQUENTIAL COMPRESSION THERAPY
Please indicate if you are currently experiencing any of the following conditions:
Severe atherosclerosis or other ischemic vascular diseases
Severe congestive cardiac failure
Existing pulmonary edema
Existing pulmonary embolism
Extreme deformity of the limbs
Malignancy in the legs
Untreated limb infections/cellulitis
Limb fractures
Presence of Lymphangiosarcoma
Acute thrombophlebitis
Acute infections
Deep Vein Thrombosis
Wounds
Lesions or tumor at or in the vicinity of application
Any condition where increased venous and lymphatic return is undesirable
COMPEX ELECTROSTIMULATION THERAPY
Please indicate if you are currently experiencing any of the following conditions:
Pacemaker
Epilepsy
Pregnancy
Hernia or eventration
THERAGUN PERCUSSIVE MASSAGE THERAPY
Please indicate if you are currently experiencing any of the following conditions:
Muscle strains
Sprains
Tendinitis
Bursitis
Fasciitis
Periostitis
Broken bones
Hypertension (high blood pressure)
Severe varicose veins
Other conditions that affect your blood vessels, such as atherosclerosis, peripheral artery disease, deep vein thrombosis or arteriosclerosis
Osteoporosis (bone degeneration)
Muscular dystrophy or other muscle disorders
Autoimmune conditions such as lupus, scleroderma and multiple sclerosis
Rheumatoid arthritis, osteoarthritis, fibromyalgia or gout
Please list any areas of discomfort that you would like us to address:
Is there any other aspects of your health that you think we should know about that impact your treatment?
I have answered these questions to the best of my understanding
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