Weight Wellness Intake Form

Patient Name*

First NameLast Name

Patient Birth Date*

MonthDayYear

Gender*

E-Mail*

example@example.com

Phone Number*

Please enter a valid phone number.

Height (inches)*

Weight (lbs)*

What are your weight loss goals?*

Please list any drug allergies*

Have you ever had (Please check all that apply)*

Other illnesses:

Do you have a personal or family history of medullary thyroid carcinoma (thyroid cancer) or multiple endocrine neoplasia syndrome type 2 (MENS2)?*

Do you have a personal history of pancreatitis?*

Please list your Current Medications*

Are you currently pregnant, breastfeeding, or trying to conceive a child?*

Exercise (per week)*

Never1-2 days3-4 days5+ days

Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption*

Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day

Include other comments regarding your Medical History

Thank you for your interested in the Weight Wellness Program at Pur Aesthetics! We pride ourselves on holistic care not only including medication, but also diet, exercise, and lifestyle modification to encourage the long term success of our patients. We offer two different weight loss medications. Lab work is required to be submitted to wellness@puraestheticsandwellness.com a minimum of 48 hours prior to your consultation and should include a Complete Metabolic Panel (CMP), Thyroid Stimulating Hormone (TSH), and Hemoglobin A1C. These labs must have been completed within the past year. If these are not received, your appointment will be cancelled or rescheduled and you will be subject to our cancellation policy. At your consultation we will review your medical history, diet, lifestyle, schedule an appointment with our dietitian, review medication administration, and answer any questions. Our Nurse Practitioners, Melissa and Emilee, will be your contacts for any questions or concerns throughout our program. Please call/text us at 574-400-8082 for any assistance!

Your signature below indicates your acceptance and understanding of the above instructions and that this form is completed to the best of your knowledge. We look forward to working with you!

The Pur Aesthetics Team

If you need to have labs drawn, you may do so with your Primary Care Provider, or at these locations:

Labcorp OnDemand

Any Lab Test Now

Ready to schedule your consultation? Click Here!

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Weight Wellness Intake Form

Patient Medical History

Healthy & Unhealthy Habits