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*
Work Phone
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Phone*
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:*

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

Diet ModificationHerbal SupplementsExercise ProgramsOther
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*

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

YesNoOther
Have you ever fainted during injections or blood draws?*
Do you have any known allergies/sensitivities to:*

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

Anti-PlateletsBlood ThinnersCorticosteriodsNo Medications listed above
Do you take antidiabetics?*
Date of Last Menses

MonthDayYear
Date
Pregnancies
Live Births
General Medical History. Have you ever been diagnosed with or currently have:*

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

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

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

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*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty: