Cavi-Lipo Client Intake Sheet

Name*
Enter Your Full Name
Phone*
Email*
Date
Address*
Street Address City State ZIP Code
Age*
Ht.
Wt
What areas of your body are you interested in contouring ?
Tell us about you eating habits
Typical Breakfast
Typical Lunch
Typical Dinner
Snacks
Water Intake ( Glasses / Day )
Caffeine
Alcohol ?
What is the worst thing on your diet ?
Do you binge eat ?
If so, what foods to you binge eat ?
What foods are your weakness ?
Do you have gas/bloating or burping after you eat ?
What foods trigger this ?
How often are your bowel movements (BM) ?
Constipation ?
Bloody BM’s ?
Any mucous in BM’s ?
Pain with BM’s ?
Any other concerns with BM’s ?
Medical History
Allergies: please specify allergen and reaction:
Current Medications/supplements:
Surgical history (year and type)/accidents/traumas/hospitalizations:
PLEASE SEE CONSENT FORM FOR LIST OF CONTRAINDICATIONS OF CAVI LIPO TREATMENTS

The success of the Cavi-Lipo program incorporates the proper number of Cavi-Lipo treatments delivered at the optimal time. My protocol calls for a minimum of 6 treatments for optimal results. Ideally, 12 treatments delivered over will produce the best possible benefit.

I'm completely committed to supporting you in achieving your personal body goals, as well as assisting you in reaching your own perfect balance in wellness. With the Cavi-Lipo program, it is mandatory that you partner with me in this commitment. To ensure optimal results and enjoy permanent benefits, it is imperative that you consistently dedicate time and effort to maintaining the following:

For the duration of the Cavi-Lipo treatment program things to do!
1. Drink the required amount of water daily (1/2 your body weight in ounces).
2. Brisk exercise (walking, swimming, etc.) for a minimum of 30 minutes daily.
3. Eat healthfully as a daily practice
I agree to the above terms in support of my wellness and optimal success with Cavi-Lipo in addition to the home instruction:
Signature*
Date*
BodyWork, by Paula Barron 413.210.3210

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Cavi-Lipo Client Intake Sheet

Tell us about you eating habits

Medical History

PLEASE SEE CONSENT FORM FOR LIST OF CONTRAINDICATIONS OF CAVI LIPO TREATMENTS

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