Intake Forms (New Patients)

Fields marked with * are required.

Preferred name:

Preferred First NameLast Name

Legal name:

First Name Last Name

Date of birth:

Sex assigned at birth:

Preferred pronouns (optional):

Primary email (this provides consent to email communication):

Cell phone number (this provides consent to SMS messaging):

Please enter a valid phone number.Format: (000) 000-0000.

Residential address:

Street Address

Street Address Line 2

CityState

Zip Code

Do you have a different shipping/delivery address?

Shipping/delivery address (if different than residential):

Street Address

Street Address Line 2

CityState

Zip Code

If you are currently under the care of a PCP or other healthcare professional, please list their name(s):

Do you have health insurance that may cover brand-name medications such as Wegovy® or Zepbound®?

Who may we thank for referring you? (i.e. family, friend, colleague, PCP, other healthcare professional, social media, google, acquaintance, etc.)

Who may we thank for referring you?

Name of referring person, if applicable:

Signature:

Do you have any medication allergies?

List medication allergies:

List other non-medication allergies, such as food or environmental allergies:

Have you been diagnosed with any of the following conditions?

List all current medications and doses, if known. If you are not taking any medications, type none.

Our office uses Tebra EHR/EMR (electronic health/medical records). Surescripts may pull up your medication history. Do you consent to our accessing your medical history/medications through Surescripts?

List non-prescription medications (vitamins, supplements, etc):

Are you currently pregnant or breast-feeding (if applicable)?

Height (feet)

Height (inches)

Highest adult weight (lb)

Current weight (lb)

Highest adult BMI

Current BMI

Highest adult weight:

Current weight and height:

WEIGHT HISTORY

Rows	Weight (lb)	Comments
What is your lowest adult weight?
What is your goal weight or size?

Lowest adult weight (lb):

Age or life stage at lowest adult weight:

Goal weight (lb):

Goal clothing size(s):

Optional: Was there another time in your life when your weight changed significantly? For example, during childhood, high school, marriage or divorce, a relationship change, pregnancy or after having children, a period of high stress, a death in the family, menopause, or after an injury or accident. If so, briefly describe the circumstances and your approximate weight, if known.

WEIGHT LOSS PROGRAMS AND OTC SUPPLEMENTS:

Rows	Past use	Current use
Acupuncture
Alli (OTC orlistat)
Amino acids
Atkins
Behavior modification (meal prep, less fast food, cooking healthier at home, etc)
Calorie restriction or calorie-conscious eating
Exercise
Food delivery service (Factor, CookUnity, Territory, Snap, etc)
Hoodia
Jenny Craig
Ketogenic
Liquid
HCG (online)
Hydroxycut
Hypnosis
Ideal Protein
Intermittent fasting
Medifast
Nutrisystem
Optifast/Optavia
Slim 4 Life
Slim-fast
South Beach
Other meal replacement
Other low-carb diet
Other OTC vitamins/minerals/supplements
Other (list below)
Weight Watchers

Which weight-loss approach has worked best for you in the past? Please include approximately how much weight you lost, if known.

List other (non-prescription) weight loss programs or supplements not listed above.

MEDICAL WEIGHT MANAGEMENT:

Rows	Past use	Current use
Amphetamines (Adderall, Ritalin, Vyvanse)
Belviq® (lorcaserin, no longer available)
Contrave® (bupropion/naltrexone)
Foundayo™ (orforglipron)
HCG (prescription strength)
Liraglutide (Victoza®, Saxenda®, compounded)
Lipotropic/MIC injections
Meridia® (sibutramine, no longer available)
Metformin
Naltrexone
Obalon™ (balloon)
Qsymia® (phentermine/topiramate)
Phentermine (Adipex-P®, Fastin, Lomaira™, Suprenza)
Other non-phentermine stimulants (phendimetrazine/Bontril, diethylpropion/Tenuate, benzphetamine/Didrex, etc)
Phen-fen (phentermine/fenfluramine, no longer available)
Semaglutide (Wegovy®, Ozempic®, Rybelsus®, compounded)
Topiramate (Topamax®)
Tirzepatide (Zepbound®, Mounjaro®, compound)
Vitamin B12 (regular B12 = cyanocobalamin)
Vitamin B12 (active B12 = hydroxo/methylcobalamin)
Xenical® (prescription strength orlistat)
Other GLP-1 diabetes medications (Trulicity®, Byetta®, Bydureon®)
Other (list below)

List other weight-related prescription medications/programs not listed above.

For any prescription weight-loss medications you have used, please provide any details you remember, such as approximate dates, dose, weight lost, or other relevant information.

If applicable, when was your most recent weight-loss injection? Please include the medication, date, and dose, if known.

Have you or a family member ever been diagnosed with any of the following?

Other

If you are adopted, how much do you know about your biological family's medical history?

Rows	Mother	Father	Maternal grandparent	Paternal grandparent	Siblings	Children
Aneurysm
Arthritis
Cancer
Diabetes
Heart disease
High blood pressure
High cholesterol
Liver disease
Kidney disease
Obesity
Weight loss surgery
Other (list below)

List any other family history you feel is relevant.

List previous surgeries and approximate year(s):

Have you had bariatric surgery?

FOR PATIENTS WHO HAVE HAD BARIATRIC SURGERY:

Rows	Yes	Year	Comments
Biliopancreatic diversion with duodenal switch (BPD-DS)
Adjustable gastric band (Lap-Band)
Gastric band removal
Roux-en-Y gastric bypass (RYGB)
One-anastomosis gastric bypass (OAGB, formerly called mini gastric bypass)
Revision surgery
Sleeve gastrectomy (VSG)
Stomach stapling (gastroplasty)
Other (list below)

List other bariatric surgery procedure not listed above.

On a scale of 1-10, how would you rate your energy level? (1 = no energy, 10 = amazing energy)

Which of the following habits or behaviors currently apply to you?

Which of the following healthy habits currently apply to you?

Which of the following situations or behaviors have contributed to weight gain for you?

New Patient Intake Form

PATIENT MEDICAL INFORMATION AND HISTORY

WEIGHT HISTORY

WEIGHT HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS