Bluegrass Medical History

1
Full Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
3
Email* This field is required.
example@example.com
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
What is your Gender?* This field is required.
Male
Female
7
Current HeightFeet and Inches
8
Current WeightRecorded in lbs.
9
Highest Recorded WeightRecorded in lbs.
10
Lowest Recorded WeightRecorded in adult life
11
Desired Weight GoalListed in lbs.
12
Previous Diet Methods Attempted and Results
Huge
Large
Normal
Small
Ok
Ok
13
Previous Weight Loss Medications Used and Results
Huge
Large
Normal
Small
Ok
Ok
14
Medical History (Check all that apply)* This field is required.
Medullary Thyroid Cancer
Chronic Nausea
Multiple Endocrine Neoplasia
Gastroparesis
Pancreatitis
Chronic Constipation
N/A
15
On average, how many calories do you consume per day?
16
How much protein do you typically eat in a day?Based on total amount consumed
Low
Moderate
High
17
How would you describe your daily carbohydrate intake?* This field is required.Based on total amount consumed
Low
Moderate
High
18
How much sugar do you consume daily?* This field is required.Based on total amount consumed
Low
Moderate
High
19
What is your biggest dietary challenge or habit you’d like to improve?
Huge
Large
Normal
Small
Ok
Ok
20
Check the conditions that apply to you or to any members of your immediate relatives:* This field is required.
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
N/A
21
Check the symptoms that you're currently experiencing:* This field is required.
Chest pain
Shortness of Breath
Joint Pain
Difficulty Urinating
Constipation
Mood Disturbances
New or Acute Vision Changes
N/A
22
Do you have history of the following? Check all that apply:* This field is required.
Bulimia
Anorexia
Body Dysmorphia
N/A
23
How would you rate your overall health?* This field is required.
Excellent
Good
Fair
Poor
24
Are you pregnant or do you have reason to believe that you may be pregnant?* This field is required.
Yes
No
25
Are you currently taking any medication?* This field is required.
Yes
No
26
Please list (or show us your own printed record) all prescriptions and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc). Please list the dosage and frequency of administration.
27
Do you have any medication allergies?* This field is required.
Yes
No
Not Sure
28
Do you use or do you have history of using tobacco?* This field is required.
Please Select
Please Select
Yes
No
29
Do you use or do you have history of using illegal drugs?* This field is required.
Please Select
Please Select
Yes
No
30
How often do you consume alcohol?* This field is required.
Daily
Weekly
Monthly
Occasionally
Never
31
Do you currently have any additional health concerns that we should be aware of? Please explain.* This field is required.
32
Name* This field is required.
First Name
Last Name
33
Phone Number* This field is required.
Please enter a valid phone number.
34
Relationship to You* This field is required.
35
Terms and Conditions* This field is required.INFORMED CONSENT: Aesthetic and wellness procedures may involve inserting a needle into your vein and infusing over a determined period, prescribed nutrients (vitamins, minerals, amino acids) or chelation agents or taking medications orally or subcutaneously, IN MODE Morpheus treatments, glacial RX treatments, BOTOX, fillers, or PDO threading. Your vitals will be measured before and after your treatment and you will be provided with risks and safety precautions for each procedure. By signing below, I agree that my consent for aesthetic and wellness therapy is entirely voluntary and I have not been offered any inducement to consent. This signature
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