Weight Loss Intake Form

Weight Loss Intake Form
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Height (inches)*
Patient Weight (lbs)*
What are your weight loss goals?*
Semiglutide (active ingredient in Ozempic)Tirzepatide (active ingredient in mounjaro)PhentermineLipo-b or b12 injections
Patient Medical History
Please list any drug allergies
AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Other illnesses:
Please list your Current Medications
Healthy & Unhealthy Habits
Never1-2 days3-4 days5+ days
I have a loose dietI have a strict dietI don't have a diet plan
I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

Patient Medical History