Weight loss intake

WEIGHT LOSS PATIENT INTAKE FORM
In order to ensure a good and productive in-person or telemedicine/telephone visit, Dr Urick wants to ensure we have the most up to date information on you.

THIS FORM IS HIPAA SECURE! We will receive it securely once you submit it.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Sex*

MaleFemale
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail*
example@example.com
Todays Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Weight loss journey information
1. How long have you been trying to lose weight? Weeks? Years?
2. Have you followed any structured diet plans such as WW, Noom, or any other program?*

YESNO
3. Do you currently exercise?*

YESNO
If YES to question 3, in what type of exercise are you engaging? Select all that apply

Cardiac - such as walking, treadmill, ellipticalWeight lifting - hand weights, exercise machinesYoga
4. Have you taken any prescription weight loss medications in the past ?

YES I did in the pastNo I never didYes I am taking one now
If yes to now or in the past, please list the medication(s)
5. Have you experienced any side effects/adverse reactions to any type of weight loss medication/over the counter weight loss supplement?

YESNO
If yes, please list the side effect(s)/adverse reaction(s)
6. What is your most recent weight/ current height?*
7. What is your weight loss goal (in lbs)
Weight Loss Medication Screening
Which compounded injectable weight loss medication interests you?*

Semaglutide (the active ingredient in Wegovy and Ozempic)Tirzepatide (the active ingredient in Zepbound and Moujaro)Open to learning about both
Do you have a personal history (or family medical history) of MEN (Multiple Endocrine Neoplasia) or medullary thyroid cancer?*

YES - (if YES, you would NOT be a candidate for either of these injectable medications)NO
Are you being treated for Type 1 or Type 2 Diabetes Mellitus?*

YESNO
Have you ever been diagnosed with Pancreatitis?*

YESNO
For females only: Are you currently pregnant or planning to become pregnant soon?

YES, currently pregnant - (If so, you would not be a candidate for either injectable)NOPlan to become pregnant soonCurrently Breastfeeding
MEDICAL HISTORY
MEDICAL CONDITIONS FOR WHICH YOU ARE BEING TREATED *
CURRENT PRESCRIPTION MEDICATIONS AND SUPPLEMENTS (if none, type NONE)*
NAME OF PRIMARY CARE PHYSICIAN (PCP). - We do not contact them but it is important that you are under the care of a Primary Care Physician (PCP) or specialist physician who is monitoring your overall health, routine blood work, etc.
* FOR EXAMPLE: DR SMITH - ORTHOPEDIC SURGEON - knee replacement; Dr Gray, Neurologist, MS. IF YOU DON'Y SEE ANY SPECIALISTS THEN TYPE "NONE"
I understand that Urick Internal Medicine does not perform routine lab work, prescribe medications other than the compounded GLP-1 medications and that I must be under the care of a PCP or specialist for such routine care. If you do not have a PCP or specialist with whom you are following for routine care, we may not be able to enroll you in our weight loss program.*

I understandI do not wish to proceed with this weight loss medication
Explanation and Waiver for treatment with compounded GLP-1 medications
HIPAA AGREEMENT FOR 2024
By typing your full name here, you acknowledge you approve of any updates to your medical record, emergency contact info, HIPAA agreement, and the Explanation and waiver for treatment with compounded GLP-1 medications.*
Signature*

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WHEN YOU PRESS "SUBMIT" BELOW, IF YOU DID NOT COMPLETE FIELDS WITH A RED ASTERISK * , THE FORM WILL NOT GO THROUGH.

If you do not receive a pop-up message stating "THANK YOU FOR YOUR SUBMISSION" or a confirmation email, then it did not go through.
CONTACTING YOU: When we need to communicate with you about appointment reminders, notification that your refill has been sent, to inquire about setting up an appointment, billing inquiries, or to communicate back and forth with you about side effects/medications changes, etc let us know how we may contact you. Please SELECT ALL THAT APPLY

Telephone/Cell phone and leave voice mailText messaging (note: texting is not HIPAA secure)Email for appointment/telemed remindersEmail to discuss side effects/medication changes/general inquiries about side effects (note: email is not HIPAA secure)
FOR PHYSICIAN/PRACTITIONER USE ONLY BELOW
FOR PHYSICIAN/PRACTITIONER USE/ DOCUMENTATION ONLY
ASSESSMENT/ PLAN
Electronically signed
Should be Empty:

WEIGHT LOSS PATIENT INTAKE FORM

Weight loss journey information

Weight Loss Medication Screening

MEDICAL HISTORY

Explanation and Waiver for treatment with compounded GLP-1 medications

HIPAA AGREEMENT FOR 2024