New Patient Information Form

Name*

First NameLast Name
Email*
example@example.com
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
HomeEmailCellWork

Past Medical History*

Rows	YES	NO
High Blood Pressure
Cancer
Depression/ Anxiety
Diabetes
Heart Problems
Insomnia
Kidney Failure
Seizures
Drug Addiction
Liver Disease
Lupus/ Rheum Arthritis
Glaucoma
PCOS/ Insulin Resistance
Thyroid Problems
Clotting Disorder
Obstructive Sleep Apnea

Surgeries
Weight Loss Surgery?   Yes   No*      When?
Other major Surgeries?
What and When?
Gall Bladder Removal?   Yes   No          When?
Medications

Check all that apply
I do not take any prescription medicationsI take herbal/ vitamin supplementsI take the following prescription medications
Mention the names of supplements / medications

I have no known drug allergiesI have drug allergies
1. Med allergic to      Type of Reaction:      Severity of Reaction:   Mild   Moderate   Severe At what age it occurred?

2. Med allergic to    . Type of Reaction:     . Severity of Reaction:   Mild   Moderate   Severe
At what age it occurred?

3. Med allergic to    Type of Reaction:    . Severity of Reaction:   Mild    Moderate   Severe At what age it occurred?   Type a label
Weight loss programs you have tried in the past:
Medically Supervised Treatment (describe)
Have you ever taken Prescription Weight Loss Meds?
DiabetesObesityHeart Rhythm ProblemsHigh Blood PressureCancerHeart AttackMental BreakdownThyroid ProblemsOther
Pregnancy History
   I am pregnant/ I have reason to believe i could be pregnant / I plan to get pregnant during the treatment.
# Births         Dates:
Tubal Ligation            Hysterectomy         Partial    Complete
Birth Control
None
Caffeine Use
Coffee      Cups/Day:
Tea      Cups/Day:
Cola  (any)
None
Alcohol use
Wine   Beer    Liquor   None
No of drinks per week:
No of drinks per month:
Tobacco use
None   Socially
No of packs per day:   Type a label
No of years of smoking:   Type a label
Inactive - no regular physical activity/sit down jobLight Activity- no organized physical activity during leisure time.Moderate Activity - occasionally involved in weekend activities ie golf/tennis/jogging/swimming.Vigorous Activity - Extensive physical exercise for at least 60 min per session 4+ x /week.
Dietary / Nutrition Restrictions:
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Rows	Name of Rx	Dose(mg)	For What Condition is this taken?
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2
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Surgeries

Medications

Pregnancy History

Caffeine Use

Alcohol use

Tobacco use