Scar Therapy Health Screening Form

Personal Details

How did you hear about the scar therapy?

Google Facebook Word of Mouth Other

Name

Date of Birth

Telephone Number

Address

Emergency Contact Name

Emergency Contact Number

Doctor Name

Doctors Address

Medical Screening

Scar Therapy Pelvic Questions

What Scars do you have on your body? (please list date occured)

Have you undergone any surgical procedures both recently and historically?

Have you previously had any therapies/treatments for your scars? If yes what treatments have your received?

Do you have discomfort from your scars? If yes please descibe

Please list below any accidents or falls you’ve sustained regardless of how long ago

If you are seeking treatment for a cancer scar, have you been in remission 5years?

Do you have any abdominal mesh implants for hernia or Diastasis Recti repair.

Do you have difficulties with breathing?

Are you currently experiencing any type of back pain?

Do you experience any pain in your body not related to your scar? Please give details

Term & Conditions:

I hereby confirm that the information stated above is answered to the best of my ability. I further fully understand that thorough and honest responses to these questions are essential to my safety. I undertake to inform my scar work therapist (Natasha Sahota) should any answers to the above information change.

Name

Date