Vaginal Hifu Consultation Form Vaginal HIFU Consultation FormΔ Subscribe First NameLast NameDate Of BirthEmailConfirm EmailAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhoneA few questions about your medical history...We need to know a few details about your medical history. The answers will be used to determine the treatment(s) used, so please answer all questions honestly and accurately.Height (imperial or metric)Current weight (imperial or metric)Lifestyle Very active Average SedentaryHow often do you exercise? Daily Few times a week NeverStress level 1 (very low stress) 2 3 4 5 (Medium Stress) 6 7 8 9 10 (Highest Stress)How much sleep do you get each night? 5 hours or less 6 hours 7 hours 8 hours 9 or moreHow much water do you drink per day? Under a litre 1 - 2 litres 3-4 litres plusDo you drink alcohol? Yes NoHow much alcohol do you drink in a typical week?Do you smoke? No - never smoked Occasional Heavy Ex-smokerDo you have a copper coil fitted? Yes NoAre you sexually active? Yes NoNumber of natural childbirths (please state number of miscarriages if appropriate)Are you taking aspirin, fish oil, vitamin E, ginkgo biloba or St. John's Wort? Yes NoYou will be asked to discontinue use of the above for at least 7 days before treatment to avoid bruising. Stop taking blood-thinning medication one week before treatment.Have you ever had a prolapse in the following areas? Bowel Vagina BladderMedical and surgical history Metal Stents in the treatment area Migraines HIV Vaginal Warts / Genital Herpes Vaginal Inflammation Infections Any Medical condition whatsoever Autoimmune Disease Diabetes STI's Recent Vaginoplasty Pubic lice Hysterectomy Implanted Electrical Devices Bell's Palsy HRT AIDS Recent Labiaplasty Coil Implants Epilepsy Menstruation HPV Vaginismus (Involuntary Tightening) Thrush Heart Condition Pregnant or lactating Haemorrhagic or bleeding disorders Tumour / Hypertension Genital Modification Candidal Vulvovaginitis Any Blood disorder Active or local skin disease that may alter wound healing Herpes Thrombosis Cervical Cancer FGM (Female Circumcision) Bartholin's cysts Metal StentsPlease list any chronic illness, current or previous:If you have undergone any cosmetic or surgical procedures in the vagina (or anywhere else) in the last 12 months, please provide details.Are you taking any prescription medications? None Accutane within the last 12 months Anticoagulants or antiplatelet drugs Immunosuppressant Drugs Anything elsePlease provide details of prescription medicationsLast smear test date Are you waiting for smear test results? Are you waiting for results on any biopsy?Finally, how did you hear about us? Magazine Advert Magazine Advert Search engine Facebook Twitter GDPR / Data Protection: The data supplied in this form will be stored electronically, and will be used solely in connection with tailoring and arranging your treatment programme. We may need to use your telephone number and/or email address in order to contact you to book appointments and discuss your treatment. We will never sell this, or any other information about you, or pass it to other clinics. Information entered into the Online Consultation Form is not used for marketing of any kind and will be used solely by CHC Aesthetics Ltd. By submitting this form, I agree that CHC Aesthetics Ltd may contact me in connection with this enquiry and that the telephone and e-mail details supplied are correct.Submit Form
