Health questionnaire

Health questionnaire.

Confidential — complete before your first session.

Select your treatment — the matching form opens automatically.

Have you already signed a form with us?

Your health declaration is valid for 3 months. If you signed a form for this treatment less than 3 months ago, simply confirm that nothing has changed.

Your details

Surname *

First name *

Phone *

Date

Time

Protocol planned

Protocol *

Absolute contraindications

Absolute contraindications (strictly prohibited)

Implanted electronic devices: pacemaker, cardiac stimulator, defibrillator — risk of interference with the electrical impulses.
Pregnancy: strictly prohibited (the induced muscle contractions and the effect on the pelvic / abdominal area are dangerous).
Serious cardiac disorders: severe arrhythmia, heart failure, history of recent infarction.
Epilepsy: repeated electrical impulses may trigger a seizure.
Deep vein thrombosis (DVT), phlebitis or serious arterial circulatory disorders: risk of dislodging a blood clot.
Cancer / active tumours: risk of stimulating proliferation or the circulation around the treated areas.
Acute infectious diseases, feverish states or bacterial inflammation: muscular effort while feverish may cause myocarditis.
Severe renal conditions: EMS releases creatine kinase (CK); failing kidneys cannot filter it properly.

Relative contraindications

Relative contraindications (medical clearance or adaptation required)

Circulatory disorders and problems (significant varicose veins, poor venous or arterial circulation).
Abdominal or inguinal hernia: intense contractions increase intra-abdominal pressure.
Neurological disturbances (neuropathies, neuromuscular conditions).
Bleeding tendency or coagulation disorders.
Skin irritation, burns or wounds: never place moist electrodes on damaged skin.
Conditions affecting muscle metabolism (e.g. diabetes): risk of hypoglycaemia during or just after the session.
Metabolic syndrome (diabetes, hypertension and obesity).
High uric acid levels.
Metabolic alterations and metabolic pathologies.
Inflammatory pathologies.
Metal implants or osteosynthesis (screws, plates): avoid stimulating the exact area directly if the implant is recent.

Tick anything that applies to you. Medical clearance will then be requested before the session.

Strict medical checklist

These boxes are mandatory. If you cannot certify any of these points, contact us before the session.

I certify that I do not wear any implanted electronic device: pacemaker, cardiac stimulator or defibrillator.I certify that I am not pregnant.I have no serious cardiac disorder: severe arrhythmia, heart failure or recent infarction.I do not have epilepsy.I have no deep vein thrombosis, phlebitis or serious arterial circulatory disorder.I have no cancer or tumour in an active phase.I have no acute infectious disease, fever or bacterial inflammation today.I have no severe renal condition.

Lifestyle commitment

Drink at least 500 ml of water 30 minutes before the session. A dehydrated muscle reacts badly to electrostimulation (risk of violent cramps and poor impulse conduction).
No alcohol, drugs or heavy medication the day before and on the day of the session.

I undertake to drink at least 500 ml of water 30 minutes before the session.I undertake to consume no alcohol, drugs or heavy medication the day before and on the day of the session.

Specific consent

I understand that the EMS protocol induces intense muscle contractions and I accept its effects (muscle fatigue, soreness) and the associated safety instructions.

Declaration & consent

I certify that my answers are accurate and complete.I understand that the proposed treatments are wellness and aesthetic treatments, and do not constitute medical acts or therapies.I understand that results may vary from one person to another.I undertake to report any change in my health before each session.

I agree that before / after photos may be taken for my personalised follow-up (optional):

Signature

Full name *

I electronically sign this questionnaire and certify the accuracy of my answers.

Protection of your data

Your data is collected solely to ensure the safety of your treatments. It is stored securely, never shared with third parties, and you may request access, rectification or deletion at any time.

Bio-Recovery VIP · HAMZULLS SL

Plaza Víctor Zurita Soler, Edificio Polsa, porta 2-3, 38204 San Cristóbal de La Laguna, Santa Cruz de Tenerife, España

+34 682 700 669 · info@biorecoveryvip.com

This health declaration is valid for 3 months from signature. At the end of this period, or earlier if your health changes, a new form must be signed.

This questionnaire does not replace a medical consultation. If in doubt about your health, consult your doctor before your session.