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*

Date

What is your age?*

What is your gender?*

Contact Phone Number*

Email Address*

example@example.com

Check the conditions that apply to you or any member of your immediate relatives:*

Check the symptoms that you're currently or have recently experienced:*

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?*

What is your height?*

What is your current weight?*

What is your desired weight?*

What other diets have you tried in the past?*

Do you feel that you are coachable?

YesNo

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)*

How did you hear about us?*

Patient Acknowledgment, Assumption of Risk & Release
Semaglutide and Tirzepatide have not been studied in patients with Type 1 diabetes and may not be appropriate for all individuals. I understand that compounded medications are not FDA-approved and may differ from commercially manufactured products in concentration, formulation, and delivery.

By signing below and submitting this form, I acknowledge and agree that:

1. I have provided complete, truthful, and accurate information regarding my medical history, medications, supplements, allergies, and health conditions. I understand that withholding or misrepresenting information may increase my risk of adverse outcomes and may disqualify me from treatment.
2. I understand that participation in a medical weight loss program involves inherent risks, including but not limited to nausea, vomiting, dehydration, electrolyte imbalance, hypoglycemia, pancreatitis, gallbladder disease, thyroid-related effects, and other known or unknown side effects.
3. I understand that strict compliance with medical guidance, dosing instructions, follow-up visits, laboratory testing, and lifestyle recommendations is required, and that noncompliance may result in reduced effectiveness, serious medical harm, or discontinuation of care.
4. I understand that individual results vary and that no guarantee has been made regarding weight loss, health outcomes, or symptom improvement.
5. I knowingly and voluntarily assume all risks, both known and unknown, associated with the use of Semaglutide and/or Tirzepatide, including compounded formulations.

To the fullest extent permitted by law, I hereby 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 any and all claims, demands, damages, liabilities, or causes of action—whether known or unknown—arising out of or related to my participation in the program or my use of prescribed or compounded medications, except in cases of proven gross negligence or willful misconduct.

I understand that I may discontinue treatment at any time and that I am responsible for promptly reporting side effects, changes in health status, or concerns to my medical team.

By signing below, I affirm that I have read, understand, and voluntarily agree to the terms above.

Today's Date*

Date

Your Signature*

Weight Loss Health History Form

Personal Health History