Rewind Health History Form

Weight Loss History
What is your current waist and hip circumference? If it's not convenient to take this right now, it's okay to skip.
What is your current weight and height?*
What has been your approximate highest and lowest weight as an adult? *
Which do you feel most accurately describes your birth weight?*

Below averageAverageAbove averageI don't know

What was your approximate weight (to the best of your memory) at the ages below throughout your life? Avg. weight is fine if you're fluctuated. Leave cells blank older than your current age.*

	Average (lbs)
5 yrs
10 yrs
15 yrs
20 yrs
30 yrs
40 yrs
50 yrs
60 yrs

Does anyone in your immediate family also have excess weight?*

NoneMotherFatherSisterBrother
Did your mother have any complications during her pregnancy with you?
ex. pre-eclampsia, gestational diabetes, etc.

Reproductive Health History
If you are using any form of contraceptive, please specify.
Date of Last menstrual period, if pre-menopausal.

MonthDayYear
Date
How many times have you been pregnant?
What were the approximate birth weights of your children?
Did you ever have any complications during pregnancy?
What was the average amount of weight (lb) gained during pregnancy?

Pharmacy & Primary Care Doctor Info

A few last questions.
Which pharmacy do you prefer?*
Please include the address of your pharmacy.
Please include the address of your pharmacy. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where do you typically get your labs done?
Do you know the address of where you get your labs?
Do you know the address of where you get your labs?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is your primary care physician (PCP)?

First NameLast Name
What is your PCP's phone number?
Please enter a valid phone number.
What is your PCP's fax number?
Please upload a copy of your health insurance card (front and back).

***Please note that if we do not have your insurance information at least 3 days before your scheduled doctor's appointment, we will need to cancel and reschedule your appointment.
Cancelof
Or you can take a photo of your health insurance card. Front of Card.
Back of Card
The cost of meal replacement shakes is about $8.72/day (or $1.74/shake). Keep in mind this will replace all your food costs (at least for yourself) during the first 3 months. Does this fit within your budget?*

YesNo
No problem. We will have someone on our team reach out to you about financial assistance.
That's it! Thanks for completing your Health History. Our team will review and follow up.
Should be Empty:

Rewind Health History Form

Weight Loss History

Diabetes History

Social History

Reproductive Health History

Eating Patterns

Pharmacy & Primary Care Doctor Info

That's it! Thanks for completing your Health History. Our team will review and follow up.