Bloom Health | History Form

Please Complete The Following Form

Time to complete: about 5 minutes

Please describe your reason for visiting Bloom Health:

Please list any medical conditions, if any:

Have you had any type of cosmetic surgery in the past?

Have you had any of the following types of aesthetic treatments in the past?

Have you had any type of bodysculpting treatment in the past?

CoolSculpting is FDA cleared for nine different areas. What body areas are you interested in treating?

What's your current body weight, approximately?

What’s your ideal body weight?

When was the last time you were at your ideal body weight?

Do you follow any specific diet plan right now?

What's your usual stress level?

None Low Medium High

How often do you exercise per week?

Do you have any favorite types of exercise?

Is your bodysculpting treatment in preparation for an upcoming event (e.g. wedding, vacation, etc.)? If so, how long until the event?

Do you take any supplements or medications that thin the blood?

Do you have any history of severe cold intolerance (e.g. Reynaud's Disease)?

Have you ever had an abdominal hernia?

Have you ever had diastasis recti following pregnancy?

Have you ever had a C-Section?

Are you pregnant or trying to become pregant?

Are you nursing?

Do you consent to photos being taken in order to monitor the results and progress of your treatment?

Do you give permission to Bloom Health to use your photos publicly for educational or promotional purposes?

How'd you hear about us?

HIPAA PRIVACY NOTICE

Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click here.

GENERAL CONSENT TO TREATMENT

By entering my initials below, I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform BLOOM HEALTH and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from BLOOM HEALTH are voluntary and I release BLOOM HEALTH, PLLC from liability and assume full responsibility thereof.

IT'S YOUR TIME TO BLOOM

Bloomfield Hills

2525 S Telegraph Rd, STE 101
Bloomfield Hills, MI 48302

Health History Form

IT'S YOUR TIME TO BLOOM

Bloomfield Hills