GLP-1 Weight Loss Intake Form

Weight Loss Program Questionnaire
Name*
Date of Birth*

MonthDayYear
Date
Age*
Address*

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*
Alcohol IntakeComfort FoodsMedical ConditionHormone ChangesBusy lifestyleExcess SnackingPerimenopauseFamily HistorySleep DisruptionsLow EnergySedentary LifestyleSweetened BeveragesOther
What foods do you crave the most and how often do you eat these foods*
Diet ModificationHerbal SupplementsExercise ProgramsOther
Please explain any items you marked above
Binge EatingSkipping MealsStress EatingPsychological FactorsOther
Please explain any items you marked above
How long has weight been an issue*
What is your current weight*
What is your current height?
YesNoOther
Have you ever fainted during injections or blood draws?*
AdhesivesBenzylAlcoholNo allergies
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
Anti-PlateletsBlood ThinnersCorticosteriodsNo Medications listed above
Do you take antidiabetics?*
Date of Last Menses

MonthDayYear
Date
Pregnancies
Live Births
Congestive Heart FailureAdrenal FatigueMultiple Endocrine Neoplasia syndrome type 2 (MEN2)High Blood PressureImmune DeficiencyHigh CholesterolEating DisorderHeart Disease/arrhythmiaLiver DiseaseMental Health DisorderPoor Wound HealingRetinopathyStroke/TIAsThyroid DiseaseGastric UlcersNot ApplicableOther
YesNo
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*

MonthDayYear
Date
Date of last blood work*

MonthDayYear
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.

Cancelof
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*

MonthDayYear
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.*
YesNo
YesNoOther
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*

MonthDayYear
Date
Should be Empty: