Weight Loss Health History Form

Weight Loss Health History Form
Thank you for completing the health history form. Our Carefree Weight Loss provider will review your history and approve you for the program.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
What is your age?*
What is your gender?*
Contact Phone Number*
Email Address*
example@example.com
Personal Health History
Check the conditions that apply to you or any member of your immediate relatives:*

Multiple Endocrine Neoplasia syndrome type 2Pregnant, planning to be or nursingPersonal or family history of medullary thyroid carcinoma (Thyroid Cancer)Personal history of pancreatitisDiabetic RetinopathyAcid reflux currently monitored by a specialistGastroparesis or bowel obstructionBlood pressure medicationsActive gallstones currently monitored by a specialistBowel Issues - frequent constipation or IBSKidney problemsDiabetesAllergic to Semaglutide or any other GLP-1 agonistNone of the aboveOther
Check the symptoms that you're currently or have recently experienced:*

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalLow blood sugarPeri/MenopauseHigh cholesterolNone of the above
Do you have diabetes?*

YesNo
What type and for how long?
Please list all medications you are currently taking. (If none, type NONE)*
Do you have any medication allergies?*

YesNoNot Sure
Please list them.
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
What is your height?*
What is your current weight?*
What is your desired weight?*
What other diets have you tried in the past?*
What is your current exercise methods and frequency?*
What is your current diet and nutrition? (# of meals a day, vegan, vegetarian or gluten free, amount of protein consumed, intermittent fasting, or other things we should know)*
Semaglutide and Tirzepatide have not been studied in patients with Type 1 diabetes.

By signing below and clicking submit, I agree to follow all instructions from my medical team carefull provided and I understand concompliance may result in little to no weight loss or serious medical harm. I hereby release Carefree Weight Loss LLC, it's RN, nurse practitioners, nutritionist, weight loss coach and any other associate from any legal harm should I exeperince an adverse side effect from Semaglutide or Tirzepatide Compounding.
Today's Date*

MonthDayYear
Date
Your Signature*

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Weight Loss Health History Form

Personal Health History