Medical History Form - Weight

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Guinea
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Iran
Iraq
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Kenya
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North Korea
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Birthdate (Only 18 and Up):* This field is required.
Date
Month
Day
Year
5
Height: feet * ' inches * ".
6
Weight * lbs.
7
Check the conditions that apply to you or to any members of your immediate relatives:* This field is required.
Cardiac disease
Type 1 Diabetes
Uncontrolled high blood pressure
Addiction history
Kidney stones
Irregular or fast heartrate
Kidney disease
Heart disease
Low blood pressure
High cholesterol
Frequent urinary tract infections
Frequent yeast infections
History of gangrene
Type 2 Diabetes
Current or history of seizure disorder
Currentor history of bulimia or anorexia
Currently taking narcotic/opioid pain medication either regularly or occasionally
Alcohol dependency
Glaucoma
Medullary thyroid cancer or history of
Multiple endocrine neoplasia syndrome type 2 (MEN2)
History of pancreatitis
History of harming yourself or concerns you may in the future
Recent major surgeries within the last 12 months
Liver disease
Depression
Current or chronic nausea
Migraines
8
Have taken or currently taking:* This field is required.
Wegovy/Saxenda/Victoza/Ozempic/Trulicity/Rybelsus/Bydureon/Byetta/Mounjaro or history of intolerance
Invokana/Jardiance/Farxiga/Steglatro or history of intolerance
Bupropion (Wellbutrin, Zyban) or Contrave or history of intolerance
Naltrexone or history of intolerance
Plenity or history of intolerance
Current migraine treatment
9
Check the symptoms that you're currently experiencing:* This field is required.
Chest pain
Shortness of breath
Palpitations
Lower extremity swelling
Bruising
Numbness/tingling
Constipation
Increased urination
Weight gain
Weight loss
Headache
10
Fasting blood sugar over 100 mg/dL* This field is required.
Yes
No
Unknown
11
List all Medications and Supplements (Current and within the last 2 weeks):* This field is required.
12
Allergies (if none write N/A)* This field is required.
13
Risk of pregnancy/current pregnancy/breast feeding* This field is required.
Yes
No
14
You understand that any medication prescribed for weight loss should be discontinued if you become pregnant? You also understand that it is advised to hold medication treatment while breastfeeding.* This field is required.
YESNO
15
What is your Gender?* This field is required.
Male
Female
Other
16
Do you use or do you have history of using tobacco?* This field is required.
No
Please Select
Yes, currently
Yes, in past
No
17
How often do you consume alcohol?* This field is required.
Daily
Weekly
Monthly
Occasionally
Never
18
List all past medical history (If none type N/A):* This field is required.
19
List all surgical history (If none type N/A):* This field is required.
20
I can use food to improve my mood or eat more when I am emotional?
Yes, frequently
Sometimes
Not commonly
Almost never
21
I have food cravings or addictive behaviors toward food?
Yes
Sometimes
Not commonly
Almost never
22
What weight loss medications have you tried before (If none type N/A):* This field is required.
23
What lifestyle changes have you tried before (If none type N/A):* This field is required.
24
How many hours do you typically sleep? blanks hours.
25
What kind of insurance do you have?* This field is required.
Commercial insurance (through an employer or marketplace)
Government funded (Medicare, Medicaid, Federal BCBS)
None, I am without insurance
26
Laboratory evaluation through blood work is strongly advised to better accommodate recommendation and treatment. These typically process through your insurance, your typical lab fees will apply. Can we send you orders for labs?* This field is required.
Yes
No
27
Signature: I agree that questions are answered to the best of my knowledge * This field is required.
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