Client Initial Evaluation and Consent Form Client Initial Evaluation and Consent Form Client Information Name * Name First First Last Last Email * Phone Number * Birthday * Age * Gender * Male Female Pronoun Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Employer Occupation How were you referred to Firefly Session Treatment? Family Member Friend Doctor OtherOther In event of an Emergency Name * Relationship to Client * Home Phone * Cell Phone Work Phone Informed Consent For Firefly Sessions Firefly sessions utilize packets of light called Photons to stimulate blood circulation to the treatment area. This results in relief of pain and reduction of symptoms associated with soft tissue injury, such as swelling. Firefly sessions also decrease the healing time associated with superficial injuries, such as burns, cuts, and contusions. Adverse effects from Firefly sessions are normally rare and temporary. These effects may include from multiple sources, in most cases involving hypersensitivity to light, preexisting medical conditions, thermal effects, excessive pressure from the treatment unit, and overstimulation. Firefly sessions can cause serious damage to the eye; therefore, it is very important to wear protective glasses that will be provided at all times during treatment. Although rare, the most common adverse effects to Firefly sessions are: Temporary increase in pain during Firefly application Temporary increase in pain in the day or days following Firefly treatment Mild bruising from stimulation of blood circulation or direct pressure of treatment unit Temporary dizziness Reactions when photosensitizing drugs are used with Firefly I have read and understand the risks of Firefly therapy. I agree to wear the protective glasses provided to me at all times during my session. Consent Signature * Consent Signature Date * Symptoms Briefly describe your current symptoms and location on your body * When did your symptoms start? * Please describe your symptom(s) * Sharp Dull Ache Numb Shooting Burning Tingling OtherOther Since your symptom(s) began, are they… * Increasing Decreasing Not Changing How often do your experience your symptoms * Constantly (76%-100%) Frequently (51%-75%) Occasionally (26%-50%) Intermittently (0%-25%) Rate the severity of your pain in the last 24 hours (0 – None, 10 – Unbearable) * 1 2 3 4 5 6 7 8 9 10 If anything, what makes this better? If anything, what makes it worse? How much have your symptoms interfered with your usual daily activities? (outside the home & housework) * Not at all A little bit Moderately Quite a bit Extremely In general, would you say your overall health right now is… * Excellent Very Good Good Fair Poor Please list any other health care providers consulted for this condition Women: Are you or is there a possibility that you may be pregnant? If yes, what is your due date? Medical Information Cardiovascular Fainting Poor Ciruclation Heart Disease Swelling of Hands/Feet High/Low Blood Pressure Swelling of Legs Irregular Heartbeat Phlebitis OtherOther Ear/Nose/Throat Dizziness Jaw Clicks Hearing Loss Bleeding Gums Sinus Infection Difficulty Swallowing Nose Bleed Sore Throat OtherOther Gastrointestinal Nausea/Vomiting Black/Bloody Stools Liver Problems Gallbladder Problems Constipation Bowel Problems Diarrhea Ulcers OtherOther Musculoskeletal Osteoporosis Broken Bones Arthritis Joints Replaced Joint Stiffness Muscle Weakness Gout OtherOther Respiratory Asthma Difficulty Breathing Bronchitis Pneumonia Cold/Flu Shortness of Breath Cough/Wheezing Emphysema OtherOther Eyes Glaucoma Glasses Double Vision Eye Pain Blurred Vision Poor Vision Color Blindness Cataracts OtherOther Genitourinary Kidney Disease Kidney Stone Burning Urination Lower Side Pain Frequent Urination Blood in Urine OtherOther Neurological Stroke Pinched Nerve Seizure Carpal Tunnel Severe Headaches Brain Aneurysm Numbness Head Injury OtherOther Hematologic/Lymphatic Hepatitis Fever Blood Clots Chills Easy Bleeding Sweats Easy Bruising Cancer OtherOther Endocrine/Constitutional Diabetes Weight Gain Thyroid Disorder Weight Loss Menstrual Problems Difficulty Sleeping OtherOther Surgeries/Hospitalizations Serious Illness or Injury Allergies Medications taken within the last two months (include over the counter and vitamins) Habits Caffeine (use/day) Alcohol Drugs (type/use/week) Tobacco: Curent Smoker (use/week) Former Smoker, quit date Never Smoked Are there any other issues concerning your health that you would like the provider to be aware of? Have you had any other significant traumas? (Auto Accidents, falls, etc.) Submit If you are human, leave this field blank.
