Weight Loss Management Pre-Appointment Questionnaire
Demographics
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Email Address
*
example@example.com
Phone
*
Format: (000) 000-0000.
Address
*
Age
*
Height
*
Weight
*
Gender
*
Male
Female
Transgender
What is your goal weight?
*
What other weight loss methods have you tried? (Check all that apply)
*
Weight Watchers
Noom
Nutrisystem
Other
Medical History Questions
1. Do you have a history of pancreatitis?
*
Yes
No
2. Are you currently pregnant or breastfeeding?
*
Yes
No
3. If you are female and have been approved as a candidate for the ZFA Weight Loss Management Therapy, you may be required to use birth control. Do you agree?
*
Yes
No
4. Do you have any of the following? (Check all that apply)
Numbness
Tingling
Frequent Urination
Frequesnt Thirst
Hunger
If you answered yes to number 4, have you been evaluated by a physician?
Yes
No
5. Do you suffer from any of the following? (Check all that apply)
Unstable Mental Health
Depression
Eating Disorder
If you answered yes to question 5, are you currently under medical supervision?
Yes
No
If you answered yes to question 5, are you currently taking medications as treatment?
Yes
No
Please list your medications:
6. Do you personally or have family history of Medullary Thyroid Carcinoma or Endocrine Neoplasia Syndrowm Type 2?
*
Yes
No
7. Do you drink more than 1 drink/day OR >7 days/week (women) or men 2/day (>14/week)?
*
Yes
No
8. Do you have a history of kidney concerns?
*
Yes
No
9. Do you think you fit the definition of obesity (BMI >30)?
*
Yes
No
10. Do you visit your doctor yearly?
*
Yes
No
Preview PDF
Submit
Should be Empty: