Weight Loss Pre-Screen

Intake Form

Fill out this mandatory Pre-Screen Assessment Questionnaire. **Filling out this form does not constitute medical advice and does not establish any kind of patient-physician relationship. A patient-physician relationship is only formed after you have formally been onboarded as a patient by the treating physician.
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Contact Number*
Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Date of Birth*

DayMonthYear
Has your doctor ever said your blood pressure was too high or too low?*

YesNo
Please provide details.
Do you have a history of thyroid cancer or MEN Multiple Endocrine Neoplasm or any type of cancer or a family history of cancer?*

YesNo
Please provide details.
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*

YesNo
Please provide details.
Has your doctor ever told you that your cholesterol was too high?*

YesNo
Please provide details.
Have you (or a family member) ever been told that you have diabetes?*

YesNo
Please provide details.
Are you taking any prescribed medications or dietary supplementation?*

YesNo
Please provide details.
Do you ever have problems sleeping?

YesNo
Are you pregnant or post-partum ( Less than 6 weeks)?*

YesNo
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?*

YesNo
Please provide details.
Have you ever been diagnosed with any of the following?*

Liver DiseaseKidney DiseaseHistory of Blood ClotsEndometriosisPCOSBreast CancerEstrogen Dependent TumorsProstrate or Testicular CancerColon CancerPrecocious PubertyNone of the Above
Provide additional information on any of conditions listed above. If none, enter N/A*
Do you have any other medical condition, injury or anything else we should be aware of that you have not mentioned?*

YesNo
Please provide details. Enter N/A if no additional information.*
When was your last physical with labs?*

MonthDayYear
Date
List all drug allergies below. Write N/A if you do not have any allergies*
What is Your Height?*
What is Your Current Weight?*
What is Your Target Weight?*
If accepted into our program, will you take the prescribed medications and follow all recommended protocols and advice given to ensure your desired results?*

YesNoOther
Upload a copy of a valid identification like a Driver's License, Passport, or State ID.*

Cancelof
Date*

MonthDayYear
Date
E-Signature (by typing out your full name, you are confirming that you have provided the correct information to be used as part of your assessment for acceptance into our weight loss program).*

Clear
Please verify that you are human*
Should be Empty:

Intake Form