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Health History for Smartlipo/Cellulaze

Dated: July 4, 2020 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
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?

List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
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?

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*
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?

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*
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?

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*
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?

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*
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?

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*
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?

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*
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?

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*
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?

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*
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?

List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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?

List any cosmetic/ plastic surgery you have had that you feel resulted in a negative outcome:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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