Laser Therapy Appointment Questionnaire

Laser Therapy Appointment Questionnaireboost2025-12-31T19:54:57+00:00

This field is for validation purposes and should be left unchanged.

Patient Name(Required)

Date of Birth(Required)

Treatment Area(Required)

Ordering Provider(Required)

Date(Required)

Contraindications (Laser therapy should not be performed)

Do you have a known history of HIV/AIDS?(Required)

Yes

Have you ever been diagnosed with leukemia (past or present)?(Required)

Yes

Is there any cancerous tissue in or near the treatment area?(Required)

Yes

Are you currently experiencing active bleeding or hemorrhage?(Required)

Yes

Do you have a pacemaker, and is the treatment area over your thoracic spine?(Required)

Yes

Are you currently pregnant, and is the treatment site near the lumbar spine or hip?(Required)

Yes

Use with Caution (Laser therapy may be performed with adjustments or further clinical assessment.)

Are you currently taking any anticoagulants (blood thinners)?(Required)

Yes

Do you have a hemorrhagic condition or bleeding predisposition?(Required)

Yes

Are you taking any photosensitizing medications (that increase light sensitivity)?(Required)

Yes

Such as: Tetracyclines (e.g., doxycycline, tetracycline) Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) Sulfonamides (e.g., sulfadiazine, sulfamethoxazole) Retinoids (e.g., isotretinoin, Tretinoin)

Do you have a history of seizures triggered by light exposure?(Required)

Yes

Informed Consent for Laser Therapy

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