Medical Weight Loss Program Intake Form
As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues- that's what we're covering If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change.*
Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc)
Please list the factors you feel have contributed to your current weight (check all that apply):
Please answer the following questions to the best of your knowledge:
Not currently, but within the last year
Not currently and longer than 1 year ago
Unexplained weight loss or gain