Weightloss-History-Form

Weight Management Medical History Form
Consultation Date

MonthDayYear
Date
How did you hear about us? (Name of person referred if applicable) First Name
Name*

First nameLast name
Date of birth*

MonthDayYear
Date
Age*
Phone*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Height*
Weight*
Occupation
Driver's License #*
State Issued*
Exp Date*
Upload State ID/Drivers License*

Cancelof
Emergency Contact
Emergency Contact
Address
PCP Information
PCP- Name
PCP-Phone
PCP Address
Patient signature*

Clear
Today's Date*

MonthDayYear
Date
What is your purpose for having Semaglutide/Cagrilintide/Tirzepatide/Retatrutide treatment? Have you tried anything in the past? Are you currently taking anything for weight management?*
What is the reason you want to lose weight?*
How long has your weight been a problem?*
Are you currently at your heaviest weight (if no, how much did you weight at your heaviest weight)?*
My worst food habit is.*
Are you a stress eater?*
Do you eat in the middle of the night?*
Does your significant other struggle with weight issues?*
Are you scared of needles/needle phobic/faint easily when you have blood taken?*
Women only answer the following:
Check if any apply

Are you trying for pregnancy or plaing pregnancy in the near future?Are you or could be pregnant?Are you on any type of hormone replacement therapy?Are you on any contraceptive methods?
Check those questions to which you answer yes (leave the others blank

Are you trying for pregnancy or planning pregnancy in the near future?

Are you or could you be pregnant?

Are you on any type of hormone replacement therapy? Are you on any contraceptive methods?
Number of live births?
Comments
Patient Signature

Clear
Men and women answer the following:
List any prescription medications you are now taking*
List any self prescribed medications, dietary supplements, or vitamins you are now taking*
Date of last complete physical examination*

MonthDayYear
Date
Date of last complete lab work*

MonthDayYear
Date
Upload recent lab work

Cancelof
List any other medical or diagnostic test you have had in the past two years
List hospitalizations, including dates of and reasons for hospitalization (including any surgeries)
List any drug, food or environmental allergies you may have*
Are you on any blood thinners?
Weekly alcohol intake?*
Do you or have you ever smoked?*
At this time, my current exercise routine includes.*
Past or current medical history
Check those questions to which you answer yes (leave the others blank
Check if applicable

Heart disease (such as heart attack, rheumatic fever, irregular heartbeat, angina, heart murmur, chest pain)High blood pressure (Hypertension)High blood cholesterolDeep vein thrombosis/blood clot in the leg (DVT) or PE (pulmonary embolism)History of dizziness, seizures or strokeAny breathing problems (such as asthma. COPD, bronchitis)Phlebitis (inflammation of a vein)Gallstones or any gallbladder disease (including jaundice)Pancreas/digestion problems (including acute or chronic pancreatitis)Stomach/duodenum/gastric ulcerSevere stomach/gut problems (incl. inflammatory bowel disease: Crohn's disease or Ulcerative colitis) Irritable bowel syndrome (IBS), gastroparesisLiver problems (including hepatitis, liver failure, fatty liver, alcoholic liver disease)Diabetes or abnormal blood-sugar testsType 1 diabetes mellitusParathyroid problems or Adrenal gland problemsAny thyroid disease/problemsMedullary thyroid cancerAnemia or other blood disorders i.e. Sickle Cell disease, ThalassemiaEating disorder (such as anorexia or bulimia)Any neurological problems (including Parkinson Disease)Mental health problems (including personality disorder, psychosis, diagnosis of depression)Self-diagnosis of depression, low mood, nervous or emotional problemsSubstance abuse (including alcohol or drugs)
Comments
Patient Signature*

Clear
Family History
Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)? Check those questions to which you answer yes (leave the others blank
Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)? Check those questions to which you answer yes (leave the others blank

Medullary thyroid cancerMultiple endocrine neoplasia 2A or 2B
Comments
Patient Signature*

Clear
Provider Signature

Clear
Date

MonthDayYear
Date
Beauty Refined, LLC

Amber Tomse, MSN, FNP-C
Should be Empty:

Weight Management Medical History Form

PCP Information

Women only answer the following:

Men and women answer the following:

Past or current medical history

Family History

Beauty Refined, LLC