Patient Intake & Consent Form
For Semaglutide Weight Loss Program Participants
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date (MM-DD-YYYY)
Gender
Please Select
Male
Female
N/A
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How did you hear about this program?
How will you be checking in?
*
Please Select
In Person
By Phone
Online (Facetime/Zoom)
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Medical History
Primary Care Physician (PCP) Name
*
Primary Care Physician (PCP) Phone
*
Primary Care Physician (PCP) Address
*
It is highly recommended to be under the care of a qualified healthcare professional who ensures your safety during exercise and monitors your medications and other health concerns, excluding stress and weight issues. If you're taking medications, especially for high blood pressure or hypothyroidism, they will require ongoing monitoring as your needs may change during and after the program.
*
I acknowledge
Current Weight
*
Highest Weight
*
Goal Weight
*
Which medications, supplements, and/or over-the-counter products do you use consistently or are currently prescribed?
*
Have you undergone any previous weight loss surgeries?
*
Yes
No
If so, when?
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Personal History
What is your occupation?
What are your main interests and hobbies?
How frequently do you exercise?
Daily
3 – 6 times a week
1 – 2 times a week
Rarely or never
What types of physical activities or movements do you enjoy?
Do you have trouble falling and/or staying asleep?
Yes
No
Sometimes
How many hours of sleep do you typically get on a regular night?
6 hours or less
7 – 8 hours
9 hours or more
Varied/Uneven sleep schedule
Do you wake up feeling refreshed in the morning?
Yes, always
Most of the time
Occasionally
Rarely or never
How would you describe your energy level?
High and consistent
Moderate and stable
Variable throughout the day
Low and consistently low
Does your energy level impact your daily activities?
Not at all
Slightly
Moderately
Significantly
Extremely
How would you generally describe your mood?
Very positive
Mostly positive
Neutral
Mostly negative
Very negative
Does your mood impact your daily life or activities?
Not at all
Slightly
Moderately
Significantly
Extremely
How would you describe your typical stress level?
Very low
Low
Moderate
High
Very high
What are your primary sources of stress?
How do you typically manage stress?
Do you have a support system with people close to you?
Yes, I have a strong support system.
Yes, I have some support from a few individuals.
No, I do not have a support system from people close to me.
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Diet and Lifestyle
Do you consume alcoholic beverages on a regular basis?
Yes, frequently
Yes, occasionally
No, I do not drink alcohol
I used to but have stopped
If yes, how many alcoholic beverages do you consume per week?
1 – 2
3 – 5
6 – 9
10 or more
Do you smoke tobacco?
Yes, regularly
Yes, occasionally
No, I do not smoke tobacco
I used to but have stopped
Do you use recreational drugs?
Yes, frequently
Yes, occasionally
No, I do not use recreational drugs
I used to but have stopped
How would you describe your appetite?
Very low
Low
Moderate
High
Very high
How many meals do you typically consume in a day?
One meal a day
Two meals a day
Three meals a day
More than three meals a day
Irregular meal pattern
Could you please describe a typical day of your food consumption, including all meals and snacks?
How much fluid do you typically consume on a daily basis?
Less than 4 cups (less than 32 ounces)
4-6 cups (32-48 ounces)
7-9 cups (56-72 ounces)
10 cups or more (80 ounces or more)
I'm not sure
Could you please specify the types of beverages you regularly consume?
Please provide details of any food allergies, intolerances, or dietary restrictions you have, along with the reasons for avoiding certain foods.
Could you please share any past challenges or difficulties you've faced in relation to food and dieting?
Health History
In this section, please provide a brief overview of your medical history. You may choose from multiple choices to describe any significant illnesses, surgeries, or chronic conditions you have experienced in the past.
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered eating pattern/tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hungr
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headaches
Lightheadedness
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Shortness of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Excessive belching/gas
Constipation
Diarrhea
Daily bowl movements
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Appointment Preferences
The Klinic is open Wednesday – Friday from 9am – 7pm and on Saturday from 9am – 4pm
Which days work best for your appointment scheduling? Please choose one or more options that suit your availability:
Wednesday
Thursday
Friday
Saturday
What time of day is most suitable for your appointment scheduling? Please select one or more options that fit your availability:
Morning (9am – 11am)
Afternoon (12pm – 4pm)
Evenings (5pm – 7pm)
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Acknowledgment and Consent
I have reviewed the following documents, which are included in the PDF version of this intake form. I fully comprehend their contents and consent to the terms outlined therein.
Signature
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