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 Name
Last Name
Age
*
Sex
*
Please Select
Female
Male
Nonbinary
Transgender
Other
Date of Birth
*
-
Month
-
Day
Year
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
City
State / Province
Postal / Zip Code
Mailing Address (if different from above)
Street Address
Street Address
City
State
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 Name
Last 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 Name
Last Name
Relation to Insured
*
Social Security Number of Primary Insured
*
Date of Birth of Primary Insured
*
-
Month
-
Day
Year
Date
Address from the back of your insurance card
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Secondary Insurance (if any)
Member ID#
Group ID#
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Pharmacy
Name of Pharmacy
*
Address
*
Street Address
Street Address Line 2
City
State / 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)?
Yes
No
Medical Conditions
Do you have a personal or family history of any of the following?
*
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia Type 2
Heart Condition
Diabetes
None
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
-
Month
-
Day
Year
Date
Menses (check all that apply)
Regular
Irregular
Painful PMS
Other
If you checked "other" above, please describe:
Are you currently pregnant or breastfeeding?
*
Yes
No
Surgeries & Hospitalizations
Procedure & Date
Procedure & Date
Procedure & Date
Allergies
Do you have an ALLERGY to a drug or other substance?
*
Please Select
No
Yes
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
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Father:
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Please Select
Brother
Sister
Son
Daughter
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Granddaughter
Grandson
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Health Status
Please Select
Alive
Deceased
Unknown
Age (if alive):
Age at Death (if deceased):
Cause of Death:
Health Problem (if any):
Relationship:
Please Select
Brother
Sister
Son
Daughter
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Granddaughter
Grandson
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Health Status
Please Select
Alive
Deceased
Unknown
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:
Please Select
Single
Partnered
Married
Divorced
Widowed
Spouse/Partner's Name:
Habits & Lifestyle
Alcohol Use
*
Yes
No
If yes, what kind?
If yes, how many per week?
Tobacco Use
*
Yes
No
If yes, what kind?
If yes, how many per week?
Recreational Drug Use
*
Yes
No
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 Constipation
Chronic Loose stools
Diverticulitis
Gastroparesis
Barrett's esophagus
Ulcers (ulcerative colitis/peptic ulcers)
Irritable Bowel Syndrome
Crohn's Disease
Gastroesophageal reflux disease (GERD)
Status Post-Op Gastric Bypass Surgery
Other
History of Eating Disorder
Yes
No
Review of Systems
Please check any current symptoms you may have:
Constitutional
Recent Fever
Night Sweats
Hot Flashes
Unexplained Weight Loss/Gain
Decline in Libido
Cardiovascular
Chest Pains/Discomfort
Palpitations
Short of breath with Exertion
Respiratory
Cough/Wheeze
Coughing up Blood
Musculoskeletal
Muscle/Joint Pain
Recent Back Pain
Sexual Function
Pain with Intercourse
Vaginal Dryness
Decrease Sexual Desire
Inability to Orgasm
Other
Gastrointestinal
Heartburn/Reflux
Blood or Change in Bowel Movement
Nausea/Vomiting
Pain in Abdomen/Plevis
Fecal Incontinence
Diarrhea/Constipation
Genitourinary
Painful/Bloody Urination
Leaking Urine
Nighttime Urination
Unusual Vaginal Bleeding
Frequent Urination
Kidney Disease
Skin
Rash
New or Change in Mole
Thin, Ridged, Splitting or Crumbling Nails
Psychiatric
Anxiety/Stress
Sleep Problems
Depression
Irritability
Neurological
Heaches
Memory Loss
Fainting
Eyes
Changes in Vision
Blood/Lymphatic
Unexplained Lumps
Easy Bruising/Bleeding
Ear/Nose/Throat
Difficulty Health
Hay Fever/Allergies
Trouble Swallowing
Endocrine
Cold/Heat Intolerance
Increased Thirst/Appetite
Pancreatitis
Diabetic Retinopathy
Signature
Submit
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Should be Empty: