• Patient History and Intake for Weight Loss

  • All fields with an asterisk must be completed for the form to submit. Thank you.

    • Patient Information  

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    • Pharmacy Information  
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    • Primary Insurance  
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    • Secondary Insurance  
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    • Medicare  
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      Pick a Date
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    • Authorization and Acknowledgement  
    • Please list the people with whom we can discuss your care and leave messages.

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    • Release of Medical Records  
    • Notice of Privacy Practices  
    • The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Minimally Invasive Surgical Associates to share my protected health information with:

    • Your Doctors  
    • Please let us know of all the doctors you see.

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    • Weight History  

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    • Dietary History  
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    • Sleep History  
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    • Office Use: STOP BANG Score (3-4 = Intermediate Risk, > 5 = High Risk):

    • GERD HQRL Scale  
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    • Patient Medication Information  
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    • Patient Medical History  
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    • Surgical History  
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    • Family History  
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    • Social History  
    • Review of Systems  
    • Please check all symptoms you currently experience, or have experienced in the past year:

    • Activity/Exercise  
    • Health Screening  
    • Attestation  
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      Pick a Date
    • Clear
    • Please note that all portions with an asterisk must be completed for the form to submit. You will be directed to a thank you page upon submission. If you do not see the page, the form was not submitted due to an error (likely a mandatory field was not completed).

    • Should be Empty:
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