NEW PATIENT INTAKE FORMS
Weight Management Medical Associates - Dr. Theresa Garza
Preferred name:
Preferred First Name
Last Name
Legal name:
First Name
Last Name
Date of birth (required):
*
-
Month
-
Day
Year
Date
Sex assigned at birth:
Please Select
Female
Male
(If applicable) Preferred pronouns:
Please Select
She/her/hers
He/him/his
They/them/theirs
Other
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.
Residential Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping/Delivery Address (if different than residential):
Street Address
Street Address Line 2
City
State / 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?
Yes, I will attach my health insurance card (front/back/RX)
No
I don't know
Yes, but I am certain they do not cover brand weight loss injections.
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?
Healthcare professional
Friend/family
Colleague
Social media (FB, instagram, Tiktok)
Online search (google)
Provide name of referring person if known.
Signature:
PATIENT MEDICAL INFORMATION AND HISTORY
Do you have any medication allergies? (required)
*
Yes (list below)
No known drug allergies
List medication allergies:
List other substance or food allergies:
Have you been diagnosed with any of the following conditions?
*
Anemia
Angina
Asthma
Bleeding disorder
Cancer
Celiac disease
Blood Clot
Diabetes
Eating disorder
Endocrine issues
Epilpesy/seizures
Fatty liver
Gallstones/gallbladder issues
GERD (acid reflux)
Gout
Heart attack
Heart condition
High blood pressure
High cholesterol
Irritable bowel
Kidney disease
Liver disease
Multiple endocrine neoplasia
Pancreatitis
PCOS (polycystic ovarian syndrome)
Pre-diabetes
Rheumatoid arthritis
Skin issues (chronic)
Sleep apnea
Stroke
Thyroid issues
Ulcerative colitis
NONE
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?
*
Yes, I consent and understand that this information allows the doctor to make safer medical recommendations.
No
List non-prescription medications (vitamins, supplements, etc):
(If applicable) - are you currently pregnant or breast-feeding?
No
Yes
I don't know
N/A
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?
*
Medullary Thyroid Carcinoma (MTC)
Endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN-2)?
(Chronic/Recurring) Pancreatitis
None of the above (no MTC, no MEN-2, no chronic pancreatitis)
I don't know.
Other
If adopted (optional):
I know my biological family's medical history.
I am not aware of my biological family's medical history.
I don't know.
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)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
SOCIAL HISTORY
"Some of my not so-healthy habits are":
Alcohol
Binging
Caffeine
Laxatives
Tobacco
Poor sleep
Recreational drugs
Skipping meals
Eating late at night
Fast food
Poor meal planning
Poor work/life balance
Eating out a lot
Too much screen/device time
Poor stress management
Excessive food delivery (Uber Eats, Door Dash, Grub Hub, Favor, etc.)
Other
"Some of my healthy habits are":
Drinking enough water
High protein
Meal planning/prep
Portion control
Healthy cooking
Consistent activity/exercise
Conscious of healthy eating
Adequate stress management
Other
What are your situational or behavior triggers for weight gain?
Anger
Divorce
Quit smoking/alcohol
Anxiety
Family
Relationship
Boredom
Insomnia
Travel
Illness/injury/surgery
Social/parties
Work
Other
Back
Next
Save
REVIEW OF SYSTEMS
CONSTITUTIONAL:
*
Fatigue/tiredness
Recent weight gain
Trouble sleeping
NONE
Fever
Weakness
Recent weight loss
Other
HEAD, EARS, EYES, NOSE, THROAT:
*
Allergies
Bleeding gums
Blurry vision
Cataracts
Double vision
Dizziness
Dry Mouth
Glasses/contacts
Glaucoma
Head injury
Hearing issues
Headache
Hoarseness
Lump(s) in throat
Migraines
Nosebleeds
Ringing in ears (tinnitus)
Swallowing (pain, problems)
Runny nose
Sore throat
None
Swollen glands
Vertigo
Other
CARDIOVASCULAR:
*
Abnormal heart beats
Arm or neck pain
Chest pain
Low blood pressure
Heart pounding
Heart failure
Heart murmur
Heart surgery or stent
Shortness of breath
Swollen legs or feet
Varicose veins
None
Other
RESPIRATORY:
*
Cough
Difficulty sleeping flat
Sputum
Shortness of breath
Snoring
None
Stop breathing at night
Wheezing
Other
GASTROINTESTINAL:
*
Abdominal pain
Bloating
Blood in stool
Cirrhosis
Diarrhea
Constipation
Heartburn
Hemorrhoids
Indigestion
Irritable bowel
Jaundice
Nausea
Reflux
Ulcers
Vomiting
None
Other
ENDOCRINE:
*
Cold all the time
Dry skin
Hair loss
Hair thinning
Night sweats
None
Swelling all over the body
Other
BREAST:
*
Abnormal mammogram
Currently breastfeeding
Fibrocystic changes
Lumps
Nipple discharge
None
Tenderness or pain
Other
MUSCULOSKELETAL:
*
Back pain
Joint pain
Weakness
Stiffness
Neck pain
None
Other
GENITOURINARY:
*
Blood in urine
Decreased libido
Difficulty urinating
Enlarged prostate
Erectile dysfunction
Frequent urination
Leakage of urine
Pain on urination
None
Prostate nodules
Vaginal dryness
Other
PSYCHIATRIC:
*
Anxiety
Bipolar
Confusion
Depression
Memory loss
None
Mood changes
Other
NEUROLOGICAL:
*
Dizziness
Fainting
Nerve pain
Numbness/tinging
Seizures
None
Vertigo
Other
SKIN:
*
Acne
Dermatitis
Dry skin
Eczema
Hives
Itchy skin
Psoriasis
Rash
None
Skin cancer
Other
Which injection would you like to start, continue, or switch to?
*
Brand Mounjaro
Brand Zepbound
Compounded tirzepatide
Brand Wegovy
Brand Ozempic
Compounded semaglutide
I don't know
Open to recommendations
Other
Check each box below indicating that you have read this:
*
Our office does not accept insurance for the consultation, monthly fees, or our professional services.
Brand medications may be covered by insurance if patients meet the criteria for anti-obesity medications. Criteria include a BMI>30 or BMI>27 w/ weight-related co-morbidity such as high blood pressure, high cholesterol, or sleep apnea.
Brands Ozempic & Mounjaro are only FDA-approved for type 2 diabetes. Any other use is off-label use.
Brands Wegovy & Zepbound are FDA-approved for weight management in patients meeting obesity requirements. Any other use is off-label use.
I understand I will be responsible for paying for the medication(s) whether insurance covers it or not.
If I do not meet insurance criteria, any coupons/savings card may not work.
If I request a prior authorization (PA) for Ozempic or Mounjaro and I do not have lab-documented type 2 diabetes, the office will charge $25 to complete a PA for off-label use. I understand that the PA does not improve my chances of insurance coverage if I do not have type 2 diabetes.
If I request a PA for Wegovy or Zepbound, the office does not charge a fee.
Compounding pharmacies & compounded medications are not regulated by the FDA. The FDA does not assess the safety, quality, or effectiveness of compounded medications. Any use of compounded medications is at my own risk.
I am aware weight loss medication is not an emergency. I will request refills well in advance.
I will kindly allow Dr. Garza and staff at least 72 business hours to respond to non-urgent emails/requests.
If applicable, which compounding pharmacy would you like to use (if known) for the injections?
*
I don't know (open to recommendations).
Axtell
Drugcrafters Frisco
Luxe Med Lewisville
SandsRX Wylie
Stonegate Austin
Texas Star Plano
Fastest option
Least expensive option
Most effective option
Other compounding pharmacy (list below)
Other
If applicable - provide name & phone number for your preferred compounding pharmacy of choice (if not listed above).
If applicable - for patients choosing a different pharmacy than those listed above: "I am responsible for verifying that my preferred pharmacy compounds semaglutide/tirzepatide, accepts RXs from Texas prescribers, and can ship/deliver to me. I am also responsible for obtaining a price list directly from them."
Yes, I already have this info.
Yes, I know someone using this pharmacy already.
Understood and will do.
Didn't read this statement. This form is already too long.
Yikes, that seems complicated and/or a lot of work.
Other
Are there any other medications you would like to start, continue, or request?
No
Regular vitamin B12 shots
Generic zofran (ondansetron dissolvable)
Lipotropic/MIC shots (email Dr. Garza for info & price list)
Methylcobalamin shots (email Dr Garza for info & price list)
I don't know.
I am aware Dr. Garza does not prescribe controlled substances like phentermine through the virtual program.
If I am requesting phentermine or any other weight loss pill, I will contact NP Melissa Pham’s new office or choose another provider for an appointment.
What is the name and phone number of your regular (local) pharmacy?
*
What other questions or concerns would you like to address to Dr. Garza or her staff? Any other feedback or comments are welcome.
REQUIRED: ATTACH DRIVERS LICENSE -- OPTIONAL: ATTACH INSURANCE CARDS (FOR MEDICATION COVERAGE ONLY)
*
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