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Health History for Smartlipo/Sculpsure

Dated: July 5, 2025 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Health History
Weight *
Height *
Pharmacy Name and Number
Occupation
Are you currently under the care of a physician?*
Name of physician ­­­­­­­­­­­
Have you ever been allergic to lidocaine or have had an adverse reaction?*
If you selected YES to being allergic to lidocaine, please explain your reaction.
Do you have any drug allergies/sensitivities?*
If you selected YES, please list any drug allergies/sensitivities (including Latex):
Are you taking Aspirin, NSAIDS, fish oil or vitamin E?*

Do you now, or have you had in the past:

History of heart attack, arrhythmia, heart surgery, cardiac stent or stroke.*
Insulin Dependent Diabetes*
Recent abdominal surgery (last 12 months)*
High blood pressure*
Pregnancy (now or within the last 3 months)*
Asthma or COPD*
Muscle, joint, or back disorder, or any previous injury still affecting you*
Type 2 Diabetes*
Hyper/Hypothyroid*
Obesity (more than 20% over ideal body weight)*
Increased cholesterol.*
History of heart problems in immediate family*
Anxiety*
Depression/ Bipolar Disorder*
Autoimmune disorder on biologic medications*
Seizure Disorder*
Keloid Formations*
MRSA infection*
Cold sores*
Herpes*
Oral estrogen therapy, tamoxifen therapy*
HIV infection*
Do you Smoke?*
If so, How many a day
Do you drink?*
If so, How often?
Hepatitis C*
Umbilical Hernia*
Bleeding disorders or blood clots*

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:

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:
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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*
Date of Birth
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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