Weight Loss Medical Intake Form

Patient General Information

Full Name*

Full Name *

First Name*

Mid. Init.

Last Name*

Email Address *

Email Address*

Date of Birth *

Date of Birth*

Age *

Age*

Gender

Gender*

Physical Characteristics *

Height (ft)*

Height (in)*

Weight*

This field is hidden when viewing the form

Height

This field is hidden when viewing the form

Heigh Inch

Goal Weight*

Weight

BMI (auto calculated based on Height and Weight)*

Number

What is your A1C?*

A1C

Primary Phone *

Primary Phone*

Alternate Phone

Patient Geographic Information

Address*

Address Address 2 City State/Province Postal Code Country

Emergency Contact Information

Full Name*

Full Name *

First Name*

Last Name*

Phone *

Phone*

Relationship *

Relationship*

Medical Information

Please list previous treatments and dates:*

Are you currently pregnant, planning to become pregnant, or breastfeeding?*

What have been your past efforts at weight loss (diets, medications, surgery)?*

Have you been diagnosed with any medical conditions (e.g., diabetes, thyroid disorders, cardiovascular disease)?*

Have you ever been treated for any mental health disorders, such as depression or eating disorders?*

Current complaints/symptoms*

Current list of medications:*

Do you have any allergies? Please list any below:*

Do you have or have had a history of cancer? If yes, please provide type below and when you were diagnosed: as well as current status:*

What are you looking to accomplish with this therapy?*

Note: Please verify that all required fields are filled in correctly before submitting the form. Once clicking the submit button, you will be taken to a "Thank You" confirmation page. If you are not redirected to the "Thank You" page, scroll up and verify you have filled in all the fields correctly. The form is not submitted until you reach the "thank you" confirmation page. If you are having issues filling out the form, please contact us at 800-531-0831 for assistance.