Whole Body Cryotherapy Intake Form
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Whole Body Cryotherapy Intake Form
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This targeted intake form is designed for cryotherapy centers, sports recovery facilities, and wellness spas offering whole body cryotherapy (WBC) treatments in cryochambers or cryosaunas. The form systematically screens clients for medical contraindications to extreme cold exposure, including cardiovascular conditions, respiratory issues, cold sensitivity disorders, and pregnancy. It captures essential health information to ensure safe treatment delivery and minimize risks associated with temperatures reaching negative 200 to 300 degrees Fahrenheit.
The template includes comprehensive sections for cardiovascular health screening, Raynaud's disease and circulation disorders, claustrophobia assessment, prior cryotherapy experience, and current medications that may affect cold tolerance. It documents client goals for cryotherapy use such as athletic recovery, pain management, inflammation reduction, or general wellness. The form also includes detailed safety acknowledgments, contraindication disclosures, and informed consent specific to whole body cryotherapy risks and benefits.
What's included
- Personal and contact information collection
- Cardiovascular health screening questions
- Respiratory condition and asthma assessment
- Cold sensitivity and Raynaud's disease check
- Pregnancy and blood pressure documentation
- Current medication and supplement list
- Prior cryotherapy experience and reactions
- Claustrophobia and anxiety screening
- Treatment goals and expectations
- Comprehensive safety contraindications list
- Informed consent for cold therapy risks
- Emergency contact information
Who uses this template
- Whole body cryotherapy centers and spas
- Sports recovery and performance facilities
- Wellness and biohacking clinics
- Athletic training and rehabilitation centers
- Luxury spa and recovery lounges
All form fields
9 fields across 2 pages. Customize any field after signing up.
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