New Patient Questionnaire

Name

FirstLast

Date

Format 00/00/0000

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Email

Cell#

Home#

Work#

Name of Emergency Contact

FirstLast

Relationship

Phone # of Emergency Contact

Date of Birth

Format 00/00/0000

Age

Gender

Ethnicity

Occupation

Work Status

Full Time
Part Time
Stay At Home
Retired

Material Status

# Of Kids

Who should we thank for referring you to us

FirstLast

Medical History

We offer solutions to help obtain the body shaped you desire. Please tell us more about your individual medical history by answering the questions below:

Autoimmune Disorder

Yes
No

AIDS/HIV

Yes
No

Anemia

Yes
No

Problems w/Bleeding

Yes
No

Problems w/Bruising

Yes
No

Acute Infestation

Yes
No

Chemical Dependency

Yes
No

Diabetes

Yes
No

Epilepsy

Yes
No

Heart Disease

Yes
No

Hepatitis A,B and C

Yes
No

Kidney Disease

Yes
No

Liver Disease

Yes
No

High Blood Pressure

Yes
No

Pacemaker

Yes
No

Thyroid Disease

Yes
No

Stroke

Yes
No

Suicide Attempts

Yes
No

Ulcers

Yes
No

Hernia

Yes
No

Are you currently under medical treatment for any conditions? If yes, please list details below.

Yes
No

If yes, please list details below.

Do you have allergies to any medications, latex and/or tape?

Yes
No

If yes, please list details below.

Are you currently taking any medications, vitamins, or herbal supplements?

Yes
No

If yes, please list below.

Have you had any surgeries (including cosmetic) in the past?

Yes
No

If yes, list type and date below.

Have you had any problems with general anesthesia?

Yes
No

If yes, please list details below.

What is your tolerance for pain? Please select only one.

Low
Medium
High

Do you smoke cigarettes?

Yes
No

How frequently

Do you drink alcohol?

Yes
No

How frequently

Do you use recreational drugs?

Yes
No

Date of last period

Are you pregnant?

Yes
No

How frequently?

Do you plan to become pregnant?

Yes
No

If yes, when?

I acknowledge that all questions are answered truthfully and that my answers are important to my medical care/outcome.

FirstLast

Date

Format 00/00/0000

YES – YOU CAN HAVE THE BODY YOU DESIRE! HELP US GET TO KNOW YOU BETTER BY ANSWERING THESE QUESTIONS.

Explain your goals here.

Have you ever considered Liposuction?

Yes
No

Have you had any elective cosmetic procedures in the past?

Yes
No

Do you exercise at least one day per week at a gym?

Yes
No

Have you paid for a diet program in the past 2 years? (e.g. Jenny Craig)

Yes
No

Have you lost weight in the past and then gained your weight back?

Yes
No

How long have you been unhappy/wanted to change certain areas of your body?

Who is supporting you with the decision regarding Liposculpture?

What areas of your body are you interested in targeting? Please list areas.

TELL US ABOUT YOUR BODY SHAPING GOALS? PLEASE SELECT ALL OF THE ANSWERS THAT ARE APPLICABLE.

Explain

What factors are preventing you from being completely happy with your body?

Genetics - it’s how I was born.
My body changed after having children and/or a c-section(s).
I am injured and/or taking medication that causes weight gain.
Menopause – my body has changed with age.
I don’t feel motivated and/or I don’t have the time to diet/exercise.

How often do you think about changing specific areas of your body?

Daily
Weekly
Monthly

Why do you want to change certain areas of your body?

I feel unattractive.
I am not able to fit into the clothes I want.
I do not feel confident.
I want to look good in a bathing suit or in the nude.
My relationship with others and/or my marriage will improve.
I have an upcoming event.

When I achieve my body shaping results, I will feel…

On a scale from 1 to 10 (10 being the highest) how ready are you to PERMANENTLY achieve your body shaping goals?