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.

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

Yes

How did you hear about us?

Do you suffer from severe anaemia?

Yes

Do you suffer from unstable or severe coronary artery disease

Yes

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

Yes

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

Yes

Do you suffer from chronic respiratory insufficiency?

Yes

Do you suffer from uncontrolled asthma?

Yes

Do you have untreated gout?

Yes

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

Yes

Do you suffer from Urticaria or allergy to the cold

Yes

Do you suffer from claustrophobia?

Yes

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

Yes

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

Yes

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

Yes

Do you suffer from Congestive Heart failure?

Yes

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

Yes

Are you pregnant?

Yes

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