Whole Body Cryotherapy - Pre Treatment Questionnaire -Light Blue Clinic

Whole Body Cryotherapy - Pre Treatment Questionnaire

Please read the following carefully and confirm whether you experience any of the following conditions which may make you an unsuitable participant in cryotherapy.

First Name

Last Name

Date of Birth

Excessive Perspiration

Yes

Raised Temperature, a fever, acute or chronic infection (bacterial or viral)

Yes

Known intolerance of cold

Yes

Skin infection or unhealed major wounds

Yes

Claustrophobia

Yes

Major surgical operation within last six months, cardiovascular disease especially angina, heart failure myocardial infarction (heart attack), cerebral vascular accident (stroke), transient ischaemic attacks, vasculitis or blood clots

Yes

Peripheral vascular disease (poor circulation), e.g. intermittent claudication, Raynaud's disease, vibration white finger

Yes

Pregnancy

Yes

Epilepsy or blackouts

Yes

Significant anaemia, cryoglobulinaemia, cryofibrinogenaemia, paroxysmal cold haemoglobinuria, cold agglutinin disease

Yes

Auto-immune disease

Yes

Overactive thyroid gland

Yes

Reflex sympathetic dystrophy

Yes

Malignancy

Yes

Under the adverse influence of alcohol or drugs

Yes

Current iso of Warfarin or immunosuppressive drugs

Yes

Respiratory (lung) disease, e.g asthma, emphysema or bronchitis

Yes

Diabetes

Yes

If you answered Yes to any of the above questions. We strongly recommend to contact your Doctor to check if Cryotherapy can be used for your condition.

Cryotherapy is safe with joint replacements and breast implants. Glasses, hearing aids, earings and body piercings should be removed. Contact lenses can be worn. You may leave the cryotherapy chamber at any time by the main chamber exit door should you require.

WBC Side Effects

Reported risks of whole-body cryotherapy are rare but include:

Cerebral bleeding,
Discomfort and dizziness,
Headache,
High blood pressure,
Frostbite,
Frozen limb,
Long-lasting shivering,
Rash called cold panniculitis,
Sudden and temporary loss of memory,
Urticaria, or hives.

I confirm that I have read the foregoing information; that I have no known reason to belive that I may suffer any of the conditioins which would make me an unsuitable participant in cryotherapy and that I have been advised that if I am in any doubts as to my suitablity to recive this treatment I should consult my GP before doing so. I further confirm that in deciding to proceed with the treatment I have not relied to any extent upon any information advice or representation by the cryochamber operator or by any person whom it is in law responsible with the exception of the information contained in the foregoing form. I acknowldge that participation in the treatment does not guarantee that cryotherapy will be succesfull in treating any particular condition. I have signed this form volountarily and agree to undergo cryotherpay today as well as when future treatments are needed. I understand that it is the cryochamber operator's responsibility to advise me to contact my GP if I have high blood pressure or a fever. Furthermore, I understand the potential side effects of the treatment.

I am a legal guardian or a parent of the above participant and I am giving a consent for the treatment to take place.

Your Signature

Date

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