• Medical Health History Form

  • Thank you for completing your health history form. A Carefree Weight Loss provider will review your information to determine your eligibility for the program. Once your review is complete, we’ll contact you with your approval and next steps.

  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • General Health History

    For GLP-1 Weight Loss Treatment
  • Check the conditions that apply to you or any member of your immediate relatives:*
  • Have you ever been diagnosed with cancer?*
  • Check the symptoms that you're currently or have recently experienced:*
  • Do you have diabetes?*
  • Do you have any medication allergies?*
  • How often do you consume alcohol?*

  • Women's Hormone Health History

  • Are you currently experiencing any of the following symptoms? Select all that apply.*
  • Do you have your uterus?*
  • Do you have your ovaries?*
  • Have you ever been diagnosed with any of the following? Select all that apply.*
  • What are your goals with hormone therapy?*
  • Are you interested in talking with our provider about hormone therapy?*

  • Men's Hormone Health History

  • Are you currently experiencing any of the following symptoms? Select all that apply.*
  • Have you previously used testosterone or hormone replacement therapy?*
  • What type of therapy have you used?*
  • Have you ever been diagnosed with any of the following? Select all that apply.*
  • What are your goals with hormone therapy?*
  • Are you interested in talking with our provider about hormone therapy?*
  • How did you hear about us?*

  • Patient Acknowledgment, Assumption of Risk & Release: Medical Weight Loss & Hormone Therapy


    I understand that treatment through Carefree Weight Loss, LLC may include medical weight loss services, hormone therapy, or a combination of treatments, as determined appropriate by my healthcare provider based on my medical history, symptoms, physical assessment, and laboratory results.


    I understand that medications used in my treatment may include, but are not limited to, Semaglutide, Tirzepatide, testosterone, estrogen, progesterone, and/or other medications or therapies prescribed by my healthcare provider.


    Semaglutide and Tirzepatide have not been studied for use in patients with Type 1 diabetes and may not be appropriate for all individuals. Hormone therapy may also not be appropriate for all individuals and requires consideration of my medical history, risk factors, symptoms, laboratory results, and ongoing clinical monitoring.


    I understand that certain medications prescribed as part of my treatment may be compounded. Compounded medications are not FDA-approved, and the FDA does not review compounded medications for safety, effectiveness, or quality before they are marketed. Compounded medications may differ from FDA-approved, commercially manufactured products in concentration, formulation, ingredients, or delivery method.


    By signing below and submitting this form, I acknowledge and agree that:
    1. Accuracy of Health Information. I have provided complete, truthful, and accurate information regarding my medical history, medications, supplements, allergies, health conditions, prior treatments, and other information requested by my healthcare provider. I understand that withholding or misrepresenting information may increase my risk of adverse outcomes and may affect my eligibility for treatment.
    2. Medical Weight Loss Risks. I understand that participation in a medical weight loss program and the use of weight loss medications may involve risks and side effects, including but not limited to nausea, vomiting, diarrhea, constipation, dehydration, electrolyte imbalance, hypoglycemia, pancreatitis, gallbladder disease, gastrointestinal complications, thyroid-related effects, allergic reactions, medication interactions, and other known or unknown adverse effects.
    3. Hormone Therapy Risks. I understand that hormone therapy involves potential risks and side effects that vary depending on the medication, dosage, route of administration, my biological sex, medical history, and individual risk factors. These may include, but are not limited to, changes in mood, headaches, acne or skin changes, hair changes, fluid retention, changes in blood pressure, changes in cholesterol or other laboratory values, changes in sexual function, fertility or reproductive effects, breast or gynecologic symptoms, changes in red blood cell levels, blood clots, cardiovascular events, and other known or unknown adverse effects.
    4. Individualized Treatment. I understand that my provider will determine whether a particular medication or therapy is medically appropriate for me. Treatment recommendations, medications, dosages, and monitoring requirements may be changed or discontinued based on my response to treatment, laboratory results, side effects, changes in my health, or my provider’s medical judgment.
    5. Compliance and Monitoring. I understand that I am responsible for following medical guidance, dosing and administration instructions, laboratory testing requirements, follow-up appointments, and other treatment recommendations. I understand that failure to follow these instructions may increase the risk of complications, reduce treatment effectiveness, or result in modification or discontinuation of treatment.
    6. No Guarantee of Results. I understand that individual results vary and that no guarantee or promise has been made regarding weight loss, body composition, hormone levels, energy, sexual function, mood, overall health, symptom improvement, or any other specific outcome.
    7. Assumption of Risk. I knowingly and voluntarily accept the risks, both known and unknown, associated with the medications and therapies prescribed to me as part of my medical weight loss and/or hormone therapy program, including risks associated with compounded medications when applicable.
    8. Reporting Changes or Side Effects. I agree to promptly notify my healthcare provider of side effects, adverse reactions, new diagnoses, pregnancy or suspected pregnancy when applicable, changes in medications or supplements, significant changes in my health, or other concerns that could affect the safety of my treatment.
    9. Right to Discontinue Treatment. I understand that I may choose to discontinue treatment at any time. I also understand that my healthcare provider may modify, suspend, or discontinue treatment when medically appropriate.

    Release and Acknowledgment
    To the fullest extent permitted by applicable law, I release, waive, and hold harmless Carefree Weight Loss, LLC, its owners, physicians, supervising physicians, registered nurses, nurse practitioners, nutritionists, health coaches, staff members, contractors, and affiliates from claims, demands, damages, liabilities, or causes of action arising out of or related to my voluntary participation in the program or my use of prescribed or compounded medications, except to the extent such liability cannot lawfully be waived or limited.

    I understand that this acknowledgment does not replace discussions with my healthcare provider regarding the specific risks, benefits, alternatives, contraindications, and potential side effects of any medication or treatment prescribed to me. I have had, or will have, the opportunity to ask questions and discuss my treatment with my healthcare provider before beginning therapy.

    By signing below, I affirm that I have read and understand the information above, have had the opportunity to ask questions, and voluntarily consent to participation in the medical weight loss and/or hormone therapy program.

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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