Medically Managed Weight Loss Patient Intake Form
DATE OF BIRTH
/
Month
/
Day
Year
Date
Date
/
Month
/
Day
Year
Date
Name
First Name
Last Name
PHONE
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
OCCUPATION
GENDER
MALE
FEMALE
STATUS
SINGLE
MARRIED
DIVORCED
WIDOWED
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MEDICAL HISTORY
This information is important to give the best quality care before proceeding with the procedure.
PRIMARY CARE PHYSICIAN
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How Were You Referred To Us?
Are you currently under the care of a medical provider? YES OR NO
*
YES
NO
Explanation of care from a current medical provider on what for, IF YES?
*
Are you Pregnant or Breastfeeding? YES OR NO
*
YES
NO
Do you have Type 1 Diabetes or Type II Diabetes? YES OR NO. IF YES, EXPLAIN*
*
YES
NO
Explanation of Type 1 Diabetes or Type II Diabetes, If YES, was selected.
*
Do you have a history of pancreatitis, liver disease, or gallstones/sludge? YES OR NO. IF YES, EXPLAIN
*
YES
NO
Explanation of Pancreatitis, Liver Disease, or Gallstones/Sludge if YES, was selected.
*
Do you have a personal history of thyroid cancer or immediate family with history of thyroid cancer? YES OR NO. IF YES, EXPLAIN
*
YES
NO
Explanation of Thyroid Cancer or Immediate Family History of Thyroid Cancer, if YES, was selected.
*
Do you have a history of diabetic retinopathy? YES OR NO
*
YES
NO
My current weight is: (in lbs)
*
How tall are you?
*
Do you have multiple medical conditions that require monitoring from multiple providers? YES OR NO. IF YES, PLEASE LIST YOUR DOCTORS
*
YES
NO
List medical conditions that require monitoring from multiple providers.
*
My current stress level is
*
LOW
MEDIUM
HIGH
My biggest stressor is
*
JOB
RELATIONSHIPS
HEALTH FINANCES
OTHER
My tobacco use is
*
NEVER
CURRENT
FORMER
QUITTING
My current alcohol us is
*
NONE
OCCASIONAL
WEEKLY
DAILY A PROBLEM
My current recreational substance use is
*
NONE
OCCASIONAL
WEEKLY
DAILY A PROBLEM
I have had a problem with drug or alcohol addiction in my past?
*
YES
NO
At this time, my overall health is
*
EXCELLENT
GOOD
FAIR
POOR
Do you have a history of diabetic retinopathy? YES OR NO
*
YES
NO
At this time, my overall health is
*
EXCELLENT
GOOD
FAIR
POOR
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Do you have a history of a recent Heart Attack or Cardiac Stent Placement? YES OR NO. IF YES, PLEASE EXPLAIN.
*
YES
NO
Explanation Heart Attack or Cardiac Stent Placement, If YES, was selected.
*
Are you taking Anticoagulants/Antiplatelets such as Plavix, Warfarin, Coumadin, or Eliquis? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation on Anticoagulants/Antiplatelets such as Plavix, Warfarin, Coumadin, or Eliquis, If YES, was selected.
*
Do you have High Blood Pressure? YES OR NO
*
YES
NO
Are you taking medicine for your blood pressure? YES OR NO. IF YES, PLEASE LIST YOUR MEDICATIONS
*
YES
NO
List of medications for blood pressure
*
Do You Have Clotting Abnormalities or Ever Had A Blood Clot? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Clotting Abnormalities or Ever Had A Blood Clot, if YES, was selected.
*
Do you have a Pacemaker? YES OR NO
*
YES
NO
Have you ever been diagnosed with a Heart Murmur? YES OR NO
*
YES
NO
Do You Have Heart Disease? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Heart Disease, if YES, was selected.
*
Do You Have Kidney Disease? YES OR NO.
*
YES
NO
Do You Have Chronic Leg Swelling? YES OR NO
*
YES
NO
Do You Have Anemia? YES OR NO
*
YES
NO
Do You Have A History of Cancer? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of History of Cancer, if YES, was selected.
*
Do you have Chest Pain, Palpitations, or Shortness of Breath?
*
Do you have a Binge Eating Disorder, or Anorexia Nervosa, or Bulimia? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Binge Eating Disorder, Anorexia Nervosa, or Bulimia, if YES, was selected.
*
Do You Have a History of Sadness/Depression? YES OR NO
*
YES
NO
Do You Have a History of Nervousness or Anxiety? YES OR NO
*
YES
NO
Do You Have a History of PTSD? YES OR NO
*
YES
NO
Do You Have a History of Bipolar Illness? YES OR NO
*
YES
NO
Do You Have a History of Migraines? YES OR NO
YES
NO
Do You Have Sleep Apnea? YES OR NO
YES
NO
Do You Have Asthma or COPD? YES OR NO
YES
NO
Do You Have Acid Reflux? YES OR NO
YES
NO
Do You Have A History of Irritable Bowel Disease/ Ulcerative Colitis/ Crohn's Disease or Stomach Ulcers? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Irritable Bowel Disease/ Ulcerative Colitis/ Crohn's Disease or Stomach Ulcers, if YES, was selected.
*
Have You Ever Been Diagnosed With Any Hormone Imbalance YES OR NO
*
YES
NO
Have You Ever Been Diagnosed With Epilepsy/Seizures/Neurological Disorders? YES OR NO
YES
NO
Do You Have Polycystic Ovaries? YES OR NO
YES
NO
Have You Gone Through Menopause? YES OR NO
YES
NO
Have You Had Gastric Surgery? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Gastric Surgery, if YES, was selected.
*
Have You Had Surgery in the Past? YES OR NO. IF YES, PLEASE EXPLAIN
*
Are You Allergic To Any Medications, Foods, Environmental, or Latex? YES OR NO. IF YES, PLEASE EXPLAIN
*
YES
NO
Explanation of Allergic To Any Medications, Foods, Environmental, or Latex, if YES, was selected.
*
Has Anyone in Your Immediate Family Have/Had: A Heart Attack; Stroke, Diabetes, Cancer, Obesity, Psychiatric condition? YES OR NO. IF YES, PLEASE EXPLAIN
My Most Important Reasons For Wanting To Change My Health: Family, Tired of Being Tired, Other:
I Decided To Get Health With My Weight Because: I can't do it on my own; Tried & Failed; Other:
My Weight At Age 20 was: (lbs)
*
My Weight One Year Ago Was: (lbs)
*
The Most I Ever Weighed (Not Pregnant) was: (lbs)
*
I Began To Gain Weight Because: Change in Hormones; Lifestyle Changes; Other:
*
I Have Bad Food Or Drink Habits. YES OR NO. IF YES, PLEASE EXPLAIN
*
I AM A Stress Eater. YES OR NO
YES
NO
I Eat In The Middle Of The Night. YES OR NO
YES
NO
My Significant Other Has A Weight Issue. YES OR NO
YES
NO
Do You Drink Sugar Filled Drinks? Soda, Fruit Juice, Sweet Tea, Diet Soda? YES OR NO
*
YES
NO
IF YES - How Much Daily? Under 16 oz or Over 32 oz
*
Are You Currently Using Weight Loss Product? IF YES, PLEASE EXPLAIN
*
Submit
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