GLP-1 Weight Loss Intake Form

Weight Loss Program Questionnaire

Name

Date of Birth

Date

Age

Address

Street Address Line 2

CityState

Zip

Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact Name

Emergency Contact Phone

Format: (000) 000-0000.

How did you hear about this clinic?

What are your main motivating factors for wanting to lose weight with Semaglutide

What reasons do you feel contribute to having excess weight? Check all that apply:

What foods do you crave the most and how often do you eat these foods

What methods and/or interventions have you used for weight loss in the past?

Other

Please explain any items you marked above

Do you feel you experience any of the following potential obstacles to weight loss? Binge EatingSkipping MealsStress Eating Psychological Factors

Please explain any items you marked above

How long has weight been an issue

What is your current weight

What is your current height?

Are you currently at your heaviest weight? If no, what was your heaviest weight?

Other

Have you ever fainted during injections or blood draws?

Do you have any known allergies/sensitivities to:

Have you ever had an adverse reaction or significant side effects to any weight loss meds?

If you marked an allergy above, or marked yes to items above please explain below

Do you take any medications that may cause increased risk of bleeding or delayed healing? If yes, which medications?

Do you take antidiabetics?

Date of Last Menses

Date

Pregnancies

Live Births

General Medical History. Have you ever been diagnosed with or currently have:

Have you or a family member ever been diagnosed with Medullary Thyroid Carcinoma (Thyroid Cancer)?

Please explain any items you marked above

Do you have any other medical issues not listed above? If yes, please describe here:

Date of last physical

Date

Date of last blood work

Date

Please upload a copy of your most recent blood work results here, or you may email a copy to our providers at ClinicalStaff@MyWholeHealthSolutions.com. This will be reviewed during your initial consultation.

Describe any abnormal results:

Do you consume alcohol? If yes please list number of drinks you consume per week

Do you Smoke? If yes, please describe how often and how much you smoke

Do you exercise regularly? If yes please describe activity frequency and duration

If there is anything else youd like the NP or Physician to know please let us know here

Patient Name

Phone

Format: (000) 000-0000.

DOB

Date

Primary Care Physician

Please list all medications, over the counter drugs, and herbal supplements you are currently taking. Please include any prescription topical creams and hormone replacement therapy medications/implants.

Do you have any allergies or sensitivities to foods, medications, implants, etc?

Have you been hospitalized or received acute medical care, including surgeries, in the past year?

Other

If yes please list all allergens and how you react to them

List all surgical procedures you have had with approximate dates

I affirm the information I have provided regarding my health history, medication record, and prior surgeries and aesthetic treatments is accurate to the best of my knowledge. I acknowledge that Whole Health Solutions Staff are not responsible for any errors that may occur as a result of any omissions or incorrect information on this form.

Patient Name Print

Patient Signature

Date