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Health History for Smartlipo/Cellulaze
Dated:
May 27, 2022
Please select who will be participating...
Adult
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First
Participant's
Name
First Name
*
Last Name
*
Phone
*
First
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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- Year -
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2019
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2011
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1919
1918
1917
1916
1915
1914
1913
First
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
First
Participant's
Signature
*
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Second
Participant's
Name
First Name
*
Last Name
*
Second
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
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13
14
15
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27
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29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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2000
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1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Second
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Third
Participant's
Name
First Name
*
Last Name
*
Third
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Third
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Fourth
Participant's
Name
First Name
*
Last Name
*
Fourth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Fourth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Fifth
Participant's
Name
First Name
*
Last Name
*
Fifth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Fifth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Sixth
Participant's
Name
First Name
*
Last Name
*
Sixth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Sixth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Seventh
Participant's
Name
First Name
*
Last Name
*
Seventh
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Seventh
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Eighth
Participant's
Name
First Name
*
Last Name
*
Eighth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Eighth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Ninth
Participant's
Name
First Name
*
Last Name
*
Ninth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Ninth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Tenth
Participant's
Name
First Name
*
Last Name
*
Tenth
Participant's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Tenth
Participant's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
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Parent or Guardian's
Name
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*
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*
Parent or Guardian's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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20
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1997
1996
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1994
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1992
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1989
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1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
Parent or Guardian's
Information
Height
Weight
Pharmacy name and number
Occupation
Currently under care of a physician:
*
No
Yes
Name of physician
Do you now, or have you had in the past:
History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.
*
No
Yes
Insulin Dependent Diabetes
*
No
Yes
Recent abdominal surgery (last 12 months)
*
No
Yes
High blood pressure
*
No
Yes
Pregnancy (now or within the last 3 months)
*
No
Yes
Asthma or COPD
*
No
Yes
Muscle, joint, or back disorder, or any previous injury still affecting you
*
No
Yes
Type 2 Diabetes
*
No
Yes
Hyper/Hypothyroid
*
No
Yes
Obesity (more than 20% over ideal body weight)
*
No
Yes
Increased cholesterol.
*
No
Yes
History of heart problems in immediate family
*
No
Yes
Anxiety
*
No
Yes
Depression/ Bipolar Disorder
*
No
Yes
Autoimmune disorder on biologic medications
*
No
Yes
Seizure Disorder
*
No
Yes
Keloid Formations
*
No
Yes
MRSA infection
*
No
Yes
Cold sores
*
No
Yes
Herpes
*
No
Yes
Oral estrogen therapy, tamoxifen therapy
*
No
Yes
HIV infection
*
No
Yes
Do you Smoke?
*
No
Yes
If so, How many a day
Drink Alcohol?
*
No
Yes
If so, How often?
Hepatitis C
*
No
Yes
Umbilical Hernia
*
No
Yes
Bleeding disorders or blood clots
*
No
Yes
Please explain any YES answers or other concerns:
Have you had any previous surgeries? If so please list all surgeries and dates performed:
List all physicians you have seen in the last 6 months:
List medications you are currently taking or have taken in the past 6 months:
Please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?
Click to customize text box label
Have you have CoolSculpting done in the past. If so, what areas?
List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
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