Intake Forms

Please COMPLETELY fill out and submit the Client Health Questionnaire form below 24 hours before your Appointment with ANY of the Modalities*

**Please also COMPLETELY fill out the HOCATT™ specific intake form below and submit if you are making an appointment to use the HOCATT™ for the first time**

**(Completely filling out the intake forms will help us to best prepare for your scheduled appointment and save you time having to finish completing the form in the office.)

** (Your information is private and will not be shared)

What to expect for your HOCATT™ Therapy Session

Please Call 480.594.5052 to schedule your appointment

We are here to advise which therapies will provide the most benefit and success for your goals based on our experience

PLEASE FILL IN ALL BOXES. IF SOMETHING DOES NOT APPLY TYPE “NA” or “NO”. TYPE “NA” OR “NO”FOR ALL RELATED QUESTIONS. IE: ” PLEASE IDENTIFY , PLEASE EXPLAIN , PLEASE LIST

Client Health Questionnaire

Personal Information:

Full Name

Date

Email Address

Cell Phone

Home Phone

Work Phone

Address

City

State

Zip

Date of Birth

Age

Occupation

Emergency Contact

Relationship

Phone

Marital Status: Maried Single

Height

Weight

Sex: Male Female

Physicians

Primary Care:

Phone:

Address:

City:

State:

Zip:

State

Health Questions:

1. How did you find My Leading Edge Wellness? Referral - Internet Search , Advertisement, Referral ( if referral please identify )

2. Have you had alternative health therapies before? Yes No

If yes, please identify

3. Which therapies are you currently using?

4. How have these therapies helped you?

Medical History

5. Are you currently under medical supervision? Yes No

If yes, please explain

6. Are you currently taking any medications? Yes No

If yes, please list below

Please explain the conditions that you have marked above:

8. Do you have any implanted electrical devices such as a pacemaker, cochlear implant, intrathecal pump, insulin pump, etc…? Yes No

If yes please list:

9. Do you have any implanted metals such as joint replacements, dental implants, mechanical heart valves, metal stents or metal staples in blood vessels? Yes No

If yes please list:

10. Do you have breast implants or organ transplants? Yes No

11. Do you take immune suppression medications? Yes No

12. Do you have hypotension? Yes No

13. Do you have Graves' Disease? Yes No

14. Do you have Epilepsy? Yes No

15. Are you pregnant? Yes No

16. Have you had any surgeries? Yes No

If yes, please identify the type and date of each surgery:

17. Is there anything else about your health history that you'd like to mention:

Consent and Release

I understand and agree that: (1) any statements made by Leading Edge Wellness and about its services have not been evaluated by the Food and Drug Administration (FDA); (2) Leading Edge Wellness does not diagnose, treat, cure or prevent disease; and (3) Leading Edge Wellness is not a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). In consideration of being permitted by Leading Edge Wellness to participate in their services, I hereby waive any and all claims and damages for personal injury or death that may occur as a result of my participation. I understand and agree that: This Consent and Release is intended to discharge in advance Leading Edge Wellness, it's officers, officials, employees, agents, and volunteers from and against all liability arising out of or connected in any way with my participation in Leading Edge Wellness; I indemnify and hold harmless Leading Edge Wellness, its officers, officials, employees, agents and volunteers from any loss, liability, cost or expense, including litigation of any form, arising out of or connected in any matter with my participation in Leading Edge Wellness; I have no physical condition which would preclude me from safely participating in Leading Edge Wellness; and I understand and agree that this Consent and Release is intended to be as broad and inclusive as permitted under the law of the State in which it is executed and that if any portion of this Consent and Release should be determined to be invalid, it is my intent that the remaining portions shall continue in full force and effect.

PRINT NAME

DATE

HOCATT™ Intake Form

1. CONTRAINDICATIONS

Do any of the following conditions apply to you?

There are circumstances during which certain modalities of the HOCATT should not be used:

2. Have you consumed at least half your body weight(pounds) or water (in ounces) today prior to your session? e.g. if you weight 150 pounds, drink at least 75 ounces of water.
Yes
No, but I will have some now please.

3. Please list ALL current daily medications, herbs and/or supplements and dose:

4. Are there any other medical conditions you have that your practitioner/ technician should be aware of?

5. It is recommended that ALL CLIENTS, regardless of heart condition, see their primary doctor before using the HOCATT. You should inform your doctor that they will be using a tempurature controlled steam and FIR sauna, and your doctor should perform the regular health-checks (e.g. take blood pressure, etc.)

6. HEART CONDITIONS & ELDERLY CLIENTS

Elderly Clients and those with known heart conditions MUST consult their cardiologist about using steam and FIR saunas, as well as Frequency Specific Microcurrents (FSM) if you would like to add an FSM program to your HOCATT session. You need an EKG (not older than 12 months) and you need to be CLEARED to use a sauna by your cardiologist before doing a HOCATT session. Your cardiologist may recommend a safe temperature range, as well as a heart rate limit that may not be exceeded. Your cardiologist might also clear you for FSM should you want to add it to your HOCATT session.

The HOCATT Plus has a heart rate monitor, so that you can monitor your heart rate throughout the rest of the day and the days that follow. You can also ask the HOCATT practitioner/ technician to set a heart rate limit (e.g. 120 beats/min). If your hearth rate exceeds this limit, then the whole system will shut down (ending the session immediatly).

7. DETOX REACTION It is very important to drink plenty of water before and after a HOCATT session, as well as throughout the rest of the day and the days that follow. Drinking water helps your body to flush out toxins. It is important to note that detoxifying the body too fast, especially if there are many toxins present, can overload the body's avenues of elimination. These include the kidneys, liver, colon, lymph system, skin and lungs. When these organs are impaired, then even mild detoxification methods can overload the remaining elimination organs. Overloading these systems can result in a detox reaction or "cleaning crisis". You may experience anything from flu-like symptoms to a skin rash. It is the body's way of trying to get rid of the toxins. While ultimately a detox reaction is a sign of a good thing, it can still be an unpleasant experience. It is much easier to get through when you support your body's normal elimination systems. When these organs are working well, and there is sufficient water and nutrient intake, then most detox reactions pass quickly, and sometimes even go unnoticed! This is why it is very important to drink plenty of water and take supplements, to help support liver, kidneys, colon and other elimination systems. Be sure to do this if you find yourself experiencing a detox reaction.

8. IMPORTANT LEGAL INFORMATION & DISCLAIMERS

THE HOCATT IS NOT A MEDICAL DEVICE. IT HAS NOT BEEN EVALUATED OR APPROVED BY THE FDA OF NDF, AND WE DO NOT CLAIM ITS INTENDED USE TO TREAT, CURE, PREVENT OR DIAGNOSE ANY DISEASE OR MEDICAL CONDITION. Though we will be glad to supervise the use of this equipment, we do not aim to treat, cure, prevent or diagnose any disease or medical condition. This information should not be used as a substitute for professional medical advice. Under US law, only a medical doctor may "treat" illness and disease with a medical origin, such as cancer. This law is to protect you from the possibility that, while you are receiving HOCATT session, an illness which may need orthodox medical attention could be getting worse. Furthermore, it is important to note that we cannot be held responsible for any health issues you may have, and we cannot be hel responsible for deterioration of any ailments that you have.

The physiological effects and efficacy Transderman Ozone and Oxygen, Whole Body Hyperthermia, Far Infared, CO2/Carbonic Acid, Frequency Specific Microcurrents, Essential Oil Infusions, and Photon Light and Colors have been documented widely and is publically available in literature. These systems are only ever intended to be "in addition" to any medical treatment that you need or are receiving. Please note that any treatment you are receiving from your Doctors should continue whilst you enjoy the HOCATT.

The manufacturer or any marketing agent cannot accept liability for any injury or fatality in relation to the use of this equipment. The client agrees to use this product at his/her own risk. and a parent/guardian takes responsibility for the fragile/minors. It is the client's responsibility to acquant him/herself with any risks associated with their physical or medical condition, as well as side effects or risks associated with the medications they are taking, and to consult a medical practitioner if in doubt.

DECLARATION:

I am aware that every safety measure will be undertaken by staff, and that this may include my refusal if deemed unsafe. The information that I have given is true complete, and I would like to go aheasd with the HOCATT session at my own risk. I understand what will occur during the session, and I take personal responsibilty for my choice in receiving sessions. I shall not hold the manufacturer, any marketing agent, physician/practitioner or technician liable for any illness, injury or worsening of any pre-existing condition that results from using this equipment

I have read the above information and understand completely what I have read.

If fainting occurs, an ambulance will be called. If you choose not to have one called, tick this box.

Full Name:

Digital Signature

Date

FILL OUT INTAKE FORM COMPLETELY AND HIT SUBMIT

TESTIMONIALS

Leading Edge Wellness™ does not provide medical advice, diagnosis or treatment through this Website. The purpose of this digital publication is to explore current research and discussions of holistic natural therapies and healthy lifestyle factors that are typically not discussed in the realm of modern allopathic medicine.

The content of this Digital Publication, such as text, graphics, images, and other material has not been evaluated by the FDA and is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read, heard or seen on this digital publication. When you schedule an appointment with Leading Edge Wellness™ you will be given natural therapies to support your healing, but they are not a substitute for medical treatment.

480-594-5052

480-594-5052

Intake Forms

Please Call 480.594.5052 to schedule your appointment

Client Health Questionnaire

Personal Information:

Physicians

Health Questions:

Medical History

Consent and Release

HOCATT™ Intake Form

FILL OUT INTAKE FORM COMPLETELY AND HIT SUBMIT

TESTIMONIALS