Clone of QUARTERLY WEIGHT MGMT PROGRESS REPORT

NEW PATIENT INTAKE FORMS

Weight Management Medical Associates - Dr. Theresa Garza
Preferred name:

Preferred First NameLast Name
Legal name:

First Name Last Name
Date of birth (required):

MonthDayYear
Date
Sex assigned at birth:
(If applicable) Preferred pronouns:
Primary email (required; this provides consent to email communication):
example@example.com
Cell phone number (required; 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 / Province

Postal / Zip Code
Shipping/Delivery Address (if different than residential):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are currently under the care of PCP or other health care professional, list name(s):
Even though our office does not accept insurance, do you have health care insurance that may cover brand 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?
Provide name of referring person if known.
Signature:
PATIENT MEDICAL INFORMATION AND HISTORY
Do you have any medication allergies? (required)
List medication allergies:
List other substance or food allergies:
Have you been diagnosed with any of the following conditions?

Other
List other medical conditions (not listed above):
(REQUIRED) List all current medications and dose if known. If you are not taking any medications, type none.
(REQUIRED) Our office uses Tebra EHR/EMR (electronic health/medical records). Surescripts may pull up your medication history. Do you give us consent to view your medical history/medications through Surescripts?
List non-prescription medications (vitamins, supplements, etc):
(If applicable) - are you currently pregnant or breast-feeding?
WEIGHT HISTORY
Highest adult weight:
Current weight and height:

WEIGHT HISTORY

Rows	Response (lbs, yes, no)	Comments
What is your lowest adult weight?
What is your goal weight or size?
OPTIONAL - feel free to add any weight at a time in your life you feel is pertinent (i.e. if heavy as a child, when graduated HS, before marriage/after divorce, before/after partner relationship, before/after kids, high stress time, death in family, before/after menopause, before/after injury or accident, etc)

WEIGHT LOSS PROGRAMS AND OTC SUPPLEMENTS:

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

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

MEDICAL WEIGHT MANAGEMENT:

Rows	Past use	Current use	Dates tried	Pounds lost (if applicable)	Comments
Amphetamines (Adderall, Ritalin, Vyvanse)
Belviq (lorcaserin - no longer available)
Contrave (bupropion/naltrexone)
HCG (prescription strength)
Liraglutide (Victoza, Saxenda, compound)
Lipotropic/MIC injections
Meridia (sibutramine - no longer available)
Metformin
Naltrexone
Obalon (balloon)
Qsymia (phentermine/topiramate)
Phentermine (Adipex, Fastin, Podimin, Lomaira, Suprenza)
Other non-phentermine stimulants (phendimetrazine/Bontril, diethylpropion/Tenuate, benzphetamine/Didrex, etc)
Phen-Fen (phentermine/fenfluoromine - no longer available)
Semaglutide (Wegovy, Ozempic, compound, oral Rybelsus)
Topiramate (topamax)
Tirzepatide (Zepbound, Mounjaro, compound)
Vitamin B12 (regular B12 = cyanocobalamin)
Vitamin B12 (active B12 = hydroxo/methylcobalamin)
Xenical (prescription strength orlistat)
Other diabetes meds (Trulicity, Byetta, Bydureon)
Other (list below)

If applicable: when was the last time you injected a weight loss injection from the table above? Date, dosage (if known), etc.
List other weight-related prescription medications/programs not listed above.
FAMILY HISTORY
Have you or anyone in your family ever had the following?

Other
If adopted (optional):

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 pertinent.
List previous surgeries (surgery and approx year):

FOR PATIENTS WHO HAVE HAD BARIATRIC SURGERY:

Rows	Yes	Year	Comments
Duodenal switch (BPD-DS)
Band placement (lap band)
Band removal
Bypass (RNY)
"Mini"
Revision
Sleeve (VSD)
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)

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
SOCIAL HISTORY
"Some of my not so-healthy habits are":

Other
"Some of my healthy habits are":

Other
What are your situational or behavior triggers for weight gain?

Other

NEW PATIENT INTAKE FORMS

PATIENT MEDICAL INFORMATION AND HISTORY

WEIGHT HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS