The Happiness Psychiatrist® Medical Weight Management Intake Form
Welcome! Please fill out and sign this HIPAA-compliant questionnaire before your first weight management consultation with Dr. Sheenie Ambardar, M.D.
Name:
First Name
Last Name
Preferred Email:
example@example.com
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Gender:
Home address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pharmacy Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name and Relationship to you:
Emergency Contact Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Weight:
Height:
What are your current weight management goals? What would successful treatment look like to you?
What motivated you to start this process at this time in your life? How long have you been working on managing your weight?
Medical History
Do you have a Primary Care Physician (PCP)?
Yes
No
If yes, please list name of PCP:
PCP Contact Number:
PCP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Physical Exam:
-
Month
-
Day
Year
Date
Date of Last Blood Work:
-
Month
-
Day
Year
Date
If you have a copy of your latest blood work, please upload it here:
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Do you have a history of Multiple Endocrine Neoplasia Type 2 (MEN2)?
Yes
No
Do you or any family members have a history of thyroid cancer (medullary thyroid carcinoma - MTC)?
Yes
No
Do you have a history of pancreatitis?
Yes
No
Do you have a history of gallbladder stones or gallbladder infection?
Yes
No
Do you have a history of diabetic retinopathy?
Yes
No
Do you have a history of low blood sugar (hypoglycemia)?
Yes
No
Do you have a history of angioedema or anaphylaxis?
Yes
No
Do you have Type 1 Diabetes Mellitus?
Yes
No
Are you allergic to semaglutide or have you ever had a hypersensitivity reaction to semaglutide?
Yes
No
Are you allergic to tirzepatide or have you ever had a hypersensitivity reaction to tirzepatide?
Yes
No
Please list all allergies:
Are you currently pregnant or do you plan to become pregnant in the near future?
Yes
No
Do you have a history of alcohol or drug addiction? If so, please describe:
Please list all prior surgeries you have had:
Have you ever tried any of the following medications?
Zepbound
Ozempic
Wegovy
Mounjaro
Saxenda
Rybelsus
Metformin
Contrave
Vyvanse
Trulicity
Victoza
Orlistat
Qsymia
Plenity
Naltrexone
Wellbutrin
Phentermine
Topamax (Topiramate)
None of the above
Other
Do you have (or have you ever had) any of the following? Please select all that apply.
Binge-Eating Disorder (BED)
Emotional Eating
Intrusive Thoughts about Food (Food Chatter)
Anorexia
Bulimia
High Blood Pressure
Low Blood Pressure
Liver Problems (e.g., fatty liver)
Kidney Problems
Bleeding Disorder
Heart Disease
Heart Attack
Heart Arrythmias
Stroke
High Cholesterol
Pre-diabetes
Seizures (Epilepsy)
Fainting Spells
Cancer
Type 1 Diabetes Mellitus
Type 2 Diabetes Mellitus
Low blood sugar (hypoglycemia)
Pancreatitis
Anemia
Sleep Apnea
Depression
Anxiety
Bipolar Disorder
ADHD
PMDD
PCOS
Asthma
Thyroid problems
Pancreatitis
Gallbladder issues
Irritable Bowel/GI Issues
Other
Please list all current medications, including dosages and prescribing physician:
Please list all vitamins, herbs, and supplements you take:
How would you describe your daily nutrition? If you could change one thing about your nutritional intake, what would it be?
How would you describe your relationship to fitness and exercise? If you could change one thing about your fitness or exercise, what would it be?
Are you open to the idea of giving yourself an injection every week?
Yes
No
Please upload any relevant prior physician's treatment summaries or notes you would like to share here:
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Additional Information you would like Dr. Ambardar to know:
By signing below, I certify that I have shared an accurate medical history on this form. If anything changes in my medical history or current medication regimen, I will notify Dr. Ambardar promptly.
Your Name:
First Name
Last Name
Today's Date:
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Date
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