Client Information &Medical History Form
Weight Management Client
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Format: (000) 000-0000.
What is your Gender?
*
Male
Female
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Check the symptoms that you're currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Are you currently taking any medication?
*
Yes
No
Do you have any allergies to medications or food?
*
Yes
No
Not Sure
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
What is your ultimate goal & time frame with weight & health?
Primary Care Physician /Bariatric Surgeon Name
First Name
Last Name
Primary Care Physician /Bariatric Surgeon phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Dietician Name
First Name
Last Name
Dietician Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: