Gitelcare Preconsultation Questionnaire

Name*

Phone Number*

Area CodePhone Number

Email Address*

example@example.com

Age

City

Insurance

What are your primary health concerns, goals and interests in our program? Please describe your reason for seeking specialized weight management services.*

Age / Weight / Height

Do you have a current primary care physician? If so, please list name, last visit, approximate date of last blood draw, and any relevant information you'd like to provide. *

Are you diagnosed with any medical conditions, or take any prescription medications daily?

Please describe your current diet, fitness and lifestyle:

How did you hear about us?

Do you have any specific questions for Dr. Dimitri?

I understand this consultation is not medical advice, and if I am seeking urgent medical care or in a medical emergency I should call 911 or go to the nearest emergency department.