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Cryotherapy Health Form

To ensure we your upcoming session is delivered safely, we require you to update us on some information about your health. This data is stored securely and you will be required to enter it before each session.
This document explains the risks and benefits of the Whole Body Cryotherapy (WBC) session you are planning to have. It does not constitute a waiver of liability by the team who will look after you.‍
Before being able to benefit from WBC you need to fill in and sign a health questionnaire where you will be informed of all the contraindications to WBC. If you have any of the conditions listed, you cannot use WBC without approval from your physician.
Furthermore, you will need to advise us of changes in your health situation prior to any subsequent sessions.The consumption of drugs is an absolute contra-indication for Whole Body Cryotherapy. Children under the age of 16 require a parental consent form.

Full name

Email

Are you filling this form out on behalf of someone else?

Are you filling this form out on behalf of someone else?

How did you hear about us?

Do you suffer from severe anaemia?

Do you suffer from severe anaemia?

Do you suffer from unstable or severe coronary artery disease

Do you suffer from unstable or severe coronary artery disease

Do you suffer from Peripheral arterial disease (grade 3 and 4)

Do you suffer from Peripheral arterial disease (grade 3 and 4)

Do you suffer from Thrombo-embolic disease (deep venous thrombosis in the past 3 months, pulmonary embolism in the past 6 months)?

Do you suffer from Thrombo-embolic disease (deep venous thrombosis in the past 3 months, pulmonary embolism in the past 6 months)?

Do you suffer from chronic respiratory insufficiency?

Do you suffer from chronic respiratory insufficiency?

Do you suffer from uncontrolled asthma?

Do you suffer from uncontrolled asthma?

Do you have untreated gout?

Do you have untreated gout?

Do you suffer from Raynaud's syndrome as secondary of Lupus or other rheumatoid disease?

Do you suffer from Raynaud's syndrome as secondary of Lupus or other rheumatoid disease?

Do you suffer from Urticaria or allergy to the cold

Do you suffer from Urticaria or allergy to the cold

Do you suffer from claustrophobia?

Do you suffer from claustrophobia?

Do you have high Blood Pressure or are you currently taking blood pressure medications?

Do you have high Blood Pressure or are you currently taking blood pressure medications?

Do you suffer from Diabetes, Poor blood sugar, uncontrolled high fevers, seizures?

Do you suffer from Diabetes, Poor blood sugar, uncontrolled high fevers, seizures?

Do you suffer from Heart Disease (CHF) or have had a heart attack in the previous 12 months?

Do you suffer from Heart Disease (CHF) or have had a heart attack in the previous 12 months?

Do you suffer from Congestive Heart failure?

Do you suffer from Congestive Heart failure?

Do you have a pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS ect?

Do you have a pacemaker or other electronic sub-cutaneous devices i.e insulin pump, DBS ect?

Are you pregnant?

Are you pregnant?
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