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.
Patient Height *
Patient Weight (lbs)*
What are your weight loss goals?*
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaNONE
Other illnesses:
Please list your Current Medications
Healthy & Unhealthy Habits
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

Patient Medical History