Infrared Sauna Intake Form *Full Name Date of Birth Month--JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day--12345678910111213141516171819202122232425262728293031 Year--20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 *E-mail Home Phone Cell Phone —Please choose an option—AKALAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Occupation How did you hear about us? If referred, name of referrer: Next Please Answer the Following Questions: *Are you pregnant? YesNo If yes, how far along? *Are you taking any medications? YesNo *Diagnosed with any medical condition that may limit or prevent your ability to sweat? YesNo *Do you have unstable angina? YesNo *Have you had a recent heart attack? YesNo *Do you have severe arterial disease? YesNo *Have you been diagnosed with any other medical condition? YesNo If “yes”, which condition? If you answered “yes” to any of the above questions; have you consulted with your medical provider about using a full spectrum infrared sauna? YesNo It is always important to maintain proper hydration levels during a full spectrum infrared sauna therapy session. Dehydration will actually increase carbohydrate utilization and cause less fat to be burned for energy. We highly recommend drinking a minimum of 4 oz. of water prior to entering the sauna and a minimum of 8 oz. of water after sauna use. BackNext FULL SPECTRUM INFRARED SAUNA AGREEMENT & ACKNOWLEDGEMENT The use of drugs or alcohol prior to or during the sauna session may lead to dizziness or unconsciousness, and should be avoided. Please consult your primary care physician if you are in doubt of your ability to use the full spectrum infrared sauna for health reasons. Persons under the age of 14 are not permitted in the sauna. Persons 14 or older are permitted in the sauna when accompanied by a supervising adult. Discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted. Sauna sessions should be limited to no more than 30 minutes and temperatures must stay below 140 degrees Fahrenheit. Water bottles are not permitted in the sauna. Water can be placed on the table in the sauna room. Clients using any medications must consult a physician or pharmacist prior to the use of the sauna. Pregnant women should not use the sauna. *I further understand that it is my responsibility to request, complete and update a new intake form on my future visits to Live Well if I experience a change to my health conditions listed/described above. I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of a full spectrum infrared sauna. I and any of my heirs, executors, representatives, or assignees hereby release all claims or liabilities of any kind sustained during the use of the full spectrum infrared sauna. Note this waiver is a formality. Research indicates that use of the far infrared sauna at Live Well is health boosting and yields improvements for its users. *Today's Date: *Signature: Back Δ
