Weight Loss Management Pre-Appointment Questionnaire
Demographics
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone
*
Format: (000) 000-0000.
Address
*
Age
*
Height
*
Weight
*
Gender
*
Female
Male
Transgender
What is your goal weight?
*
What other weight loss methods have you tried?
*
Weight Watchers
Noom
Nutrisystem
Other
Do you have a history of pancreatitis?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Do you have any numbness/tingling, frequent urination, frequent thirst, or hunger?
*
Yes
No
Do you suffer from unstable mental health, depression, or eating disorders?
*
Yes
No
Do you personally or have family history of medullary thyroid carcinoma or Endocrine Neoplasia Syndrome type 2?
*
Yes
No
Do you drink more than 1 drink/day OR >7days/week (woman) or men 2/day (>14/week)?
*
Yes
No
Do you have a history of kidney concerns?
*
Yes
No
Do you think you fit the definition of obesity (BMI >30)?
*
Yes
No
Do you visit your doctor yearly?
*
Yes
No
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