Weight Loss Patient Intake Form

Weight Loss Intake Form

Please take your time filling out this questionnaire completely and honestly. You should commit at least one hour to complete this form. Information is acquired to evaluate your health profile from an integrative medicine perspective. However, it should also be the starting point for you to begin to see habits and exposures that prevent you from obtaining your weight loss goal.
Patient Name*

First NameLast Name
Age*
Sex*
Date of Birth*

MonthDayYear
Date
Weight*
Pounds
Height*
Contact Information
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address

CityState

Zip Code
Current Medical Team
Primary Physician
PCP Phone Number
Please enter a valid phone number.
OB/GYN
OB/GYN Phone Number
Please enter a valid phone number.
Referred By
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Insurance

Your weight loss visits will not be billed to insurance, we collect your insurance information strictly for lab work. Insurance is only billed for medical visits as long as there's a specific contractual agreement with the patient's insurance plan & Tula Wellness.
Name of Insurance Carrier*
Member ID#*
Group ID#*
Name of Primary Insured (if different than above)

First NameLast Name
Relation to Insured*
Social Security Number of Primary Insured*
Date of Birth of Primary Insured*

MonthDayYear
Date
Address from the back of your insurance card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Secondary Insurance (if any)
Member ID#
Group ID#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Pharmacy
Name of Pharmacy*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weight Loss History
What are your weight loss goals?*
What have you tried in the past to achieve them?*
Are you interested in treatments that can freeze(Cool Sculpt)/burn fat and build muscle(EmSculpt)?

YesNo
Medical Conditions
Do you have a personal or family history of any of the following?*

Medullary Thyroid CancerMultiple Endocrine Neoplasia Type 2Heart ConditionDiabetesNone
Please list the name and diagnosis date of any current medical conditions.
Please list the name and diagnosis date of any previous or childhood medical conditions.
Women's Health History
Date of last menstrual period

MonthDayYear
Date
Menses (check all that apply)

RegularIrregularPainful PMSOther
If you checked "other" above, please describe:
Are you currently pregnant or breastfeeding?*

YesNo
Surgeries & Hospitalizations
Procedure & Date
Procedure & Date
Procedure & Date
Allergies
Do you have an ALLERGY to a drug or other substance?*
If yes, please describe all.
Current Prescription Medications
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.*
Supplements and Over-The-Counter
Drug Name(s), Strength(s), Dosage(s). If none, please write NONE.*
Family Health History

Please tell me about your family. Please include any family member with a history of tuberculosis, diabetes, cancer, emphysema, kidney disease, ulcer, nervous breakdown or gall bladder disease.
Mother:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Father:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Health Status
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Additional information related to your Family Medical History you would like me to know:
Social and Socioeconomic History
Occupation:
Employer:
Present Marital Status:
Spouse/Partner's Name:
Habits & Lifestyle
Alcohol Use*

YesNo
If yes, what kind?
If yes, how many per week?
Tobacco Use*

YesNo
If yes, what kind?
If yes, how many per week?
Recreational Drug Use*

YesNo
If yes, what kind?
If yes, how many per week?
What are the major stressors in your life?*

Describe your energy level throughout a typical day rating on a scale of 1-10: 1=Extreme Fatigue 10=Feeling Great and Energized*

	1-10
Early Morning
Mid Morning to Noon
Mid Afternoon
Evening

Digestive Tract Problems

Chronic ConstipationChronic Loose stoolsDiverticulitisGastroparesisBarrett's esophagusUlcers (ulcerative colitis/peptic ulcers)Irritable Bowel SyndromeCrohn's DiseaseGastroesophageal reflux disease (GERD)Status Post-Op Gastric Bypass SurgeryOther
History of Eating Disorder

YesNo
Review of Systems

Please check any current symptoms you may have:
Constitutional

Recent FeverNight SweatsHot FlashesUnexplained Weight Loss/GainDecline in Libido
Cardiovascular

Chest Pains/DiscomfortPalpitationsShort of breath with Exertion
Respiratory

Cough/WheezeCoughing up Blood
Musculoskeletal

Muscle/Joint PainRecent Back Pain
Sexual Function

Pain with IntercourseVaginal DrynessDecrease Sexual DesireInability to OrgasmOther
Gastrointestinal

Heartburn/RefluxBlood or Change in Bowel MovementNausea/VomitingPain in Abdomen/PlevisFecal IncontinenceDiarrhea/Constipation
Genitourinary

Painful/Bloody UrinationLeaking UrineNighttime UrinationUnusual Vaginal BleedingFrequent UrinationKidney Disease
Skin

RashNew or Change in MoleThin, Ridged, Splitting or Crumbling Nails
Psychiatric

Anxiety/StressSleep ProblemsDepressionIrritability
Neurological

HeachesMemory LossFainting
Eyes

Changes in Vision
Blood/Lymphatic

Unexplained LumpsEasy Bruising/Bleeding
Ear/Nose/Throat

Difficulty HealthHay Fever/AllergiesTrouble Swallowing
Endocrine

Cold/Heat IntoleranceIncreased Thirst/AppetitePancreatitisDiabetic Retinopathy
Signature

Clear
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Should be Empty:

Weight Loss Intake Form

Contact Information

Current Medical Team

Referred By

Emergency Contact

Insurance

Preferred Pharmacy

Weight Loss History

Medical Conditions

Women's Health History

Surgeries & Hospitalizations

Allergies

Current Prescription Medications

Supplements and Over-The-Counter

Family Health History

Mother:

Father:

Social and Socioeconomic History

Habits & Lifestyle

Review of Systems

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