Sudbury
Laser Health Clinic
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Copyright © 2009 Sudbury Laser
Health Clinic. All rights reserved
Your name:
Address:
Your email address:
City
Province
Postal code:
Home phone number:
 Work Phone Number
 Cell phone number
* By providing your phone number you agree that the Sudbury Laser Health Clinic may contact you at these numbers.
Next of Kin
Name:
 Phone number:
 Relationship:
Personal information
Your Age:
 Sex
 Weight:
 Height:
Date of Birth
How did you hear of
our services:
 Have you visited
our clinic past?
Smoker's case History:
How long have you been smoking?
How many cigarettes do you a day
on average?
List the top 3 reasons why you want
to quit smoking
Have you tried to quit smoking
before??
How many times have you tried
Please check all the methods you have tried;
Cold Turkey
 Nicotine Inhalers
 Hypnosis
Nicotine patches
 Low Level Laser
 Herbal products
Nicotine gum
 Acupuncture
 Zyban/ Wellbutrin /
Chanpix
Other
Are you currently using any
of the above quit-smoking
products or treatments?
Health Review:
To determine your eligibility to be treated for smoking cessation using Low Level Laser Therapy
(LLLT).It is important for us to know if you currently suffer from any of the following medical
conditions or are receiving certain treatments please check all that apply
Active Cancers
 Epilepsy
 Injected steroids
Photo sensitivity
 Psychiatric illness
 Pacemaker
Radiation treatment
 Anxiety or Panic disorder
 Asthma exc
Other
If Yes Explain:
Are you currently using any drugs/medications?
Have you smoked marijuana in the last 48 hours?
Do you suffer from any skin conditions?
Are you pregnant or trying to conceive?
Date of last menstrual period:
Are you being treated for any medical condition?
Do you have a thyroid condition or are you on
Thyroid Replacement Therapy?
Have you set up your appointment with the  
Sudbury laser health clinic for your quit Date?
(*Protocol does not allow LLLT treatment on pregnant woman)
If you have any doubts that LLLT is appropriate for you, consult your physician before starting
treatment
By submitting this form you agree that you have read and agreed with the Sudbury
Laser Health Clinics TERMS AND CONDITIONS.  You agree That the information
above is true to the best of you knowledge and this form has been filled out by
the named Client above.
*The information gather by the Sudbury Laser Health Clinic will remain strictly confidential, and at no time will
any information be shared with any outside source without your written permission. The contact information
may be use by our clinic or any other professional aided in your cause or to contact you for a follow up.
Client Intake Form