Weight Loss Intake Form

  • Weight Loss Intake Form

    Registration Form
  • Format: (000) 000-0000.
  • Birthdate*
     / /

  • Medical History

  • Medical History Continued

  • Do you have any allergies to medication, food or latex products?
  • Phentermine is not recommended for clients with a history or current condition of any of the following: (Do you have a history of any of the following? Check all that apply.)
  • Past Medical History (check all that apply)
  • Family Medical History- Has any blood relative ever had any of the following? Check all that apply.
  • Women only: Are you currently breastfeeding?
  • Women only: Are you or do you suspect you may be pregnant?
  • Women only: Date of last menstrual period
     - -

  • Dietary History

  • Describe your daily caffeine intake:
  • What type of caffeine do you drink?
  • Do you awaken hungry during the night?

  • Activity Level

  • Which one accurately describes you?
  • Have you ever used the services of a personal trainer?

  • Social History

    Tobacco, Alcohol, Drugs
  • Do you or have you ever smoked?
  • Do you drink alcohol?
  • If yes, what type do you drink?
  • Do you use or have a history of use of illicit drugs?

  • I have fully disclosed all of my medical history. I understand that it is my responsibility to inform and update the medical provider of any changes in my health status and medical history. I understand that omition of information may affect my plan of treatment. 

  • Decatur Internal Medicine Center Weight Loss Clinic

    Insurance Information

  • Medical insurance policies do not typically cover weight management care and related expenses, including labratory testing, electrocardiograms, prescription medication and related supplements. If your primary diagnosis is obesity, you may NOT bill your insurance company for a co-morbid condition. Doing so may result in a charge of fraud. 

     

    An appropriate receipt of payment will be provided to you.

  • Please call our office before visiting 256-350-6363. PLEASE WAIT 24 HOURS AFTER FILLING OUT THIS FORM AND TALKING TO A STAFF MEMBER TO COME IN. Walk in hours for New Patients are Monday-Thursday 1-3pm.

    Patients must have commercial insurance for certain medications. Please call your insurance to check on medication coverage.
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