EXILIS BODY TREATMENT RECORD - MALE
First Name
*
Last Name
*
Email
*
Patient email on file
Date of treatment
*
/
Month
/
Day
Year
Date
Treatment Number
*
1
2
3
4
5
6
Location of grounding pad
*
Upper back
Buttocks
Other
Description of grounding pad location
*
Photos Taken
*
Yes
No
Hydration Status
*
Normal
Below
N/A or not measured
Treatment Measurements
*
Area
Inches
1
2
3
No measurements taken
*
Yes
Description of area measured
*
Treatment Area(s)
*
Treatment Area(s)
*
Type a question
*
Section 1
Section 2
Section 3
Treatment Area(s)
Power/Min Power
Cooling Setting (°C)
Maximum Temp (°C)
# of Zone per area
Total Tx Time (Min) (Per area)
Patient Positioning During Treatment
Treatment Setting
*
None
Mild
Moderate
Servere
Rate patient discomfort during treatment
Rate erythema immediately post treatment
Rate erythema immediately post treatment
Notes
*
Provider Name
*
Provider Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
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