Medical History Intake Form
Start the process by completing our form!
How does this work?
First, you’ll provide some basic information about yourself, your lifestyle, and your medical history. Your doctor will use this information to evaluate your symptoms and, if appropriate, prescribe medication for treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
What is your gender at birth?
*
Please Select
Male
Female
N/A
What is your height?
*
What is your current weight?
*
What is your goal weight?
*
Contact Number
*
Email Address
*
imreadytoloseweight@gmail.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Check the conditions that you have been diagnosed with:
*
Cancer
Heart disease/Heart attack
Hypertension
Low Blood Pressure
Psychiatric disorder
Epilepsy
CKD (Kidney Disease)
Type 1 Diabetes
Type 2 Diabetes
Prediabetes
Kidney Stones
High Cholesterol
Heart Failure
Glaucoma
Gout
Cystic Fibrosis
Low Sodium
Obstructive Sleep Apnea
None of these
Other
Check the conditions that you or a family member ever been diagnosed with any of the following conditions
*
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia Type-2
Pancreatitis
Gastroparesis (Delayed Stomach Emptying)
None of the above
Check the symptoms that you' re currently experiencing, if any:
Chest pain
Shortness of Breath
Bleeding
None
Have you ever had any of these surgeries?
*
Gastric Bypass (Roux-en-Y)
Duodenal Switch
Lap band
Gastric Sleeve
None of these
Are you currently or have you ever taken a GLP-1 medication?
*
Yes
No
Please list them.
Are you currently taking any medications or supplements?
*
Yes
No
Please list them.
Do you have any allergies?
*
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
*
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume 5 or more alcoholic drinks in one occasion?
*
Please Select
Never
A Few Times a Year
Once a Month
Once a Week
Daily or almost daily
Where did you hear about us from?
Friend, Clinic, Website, Google, etc
Signature
*
By signing above you agree that information provided above is factual, accurate, and up to date. You agree to be contacted by OWL personnel in preparation for a tele-health visit. You agree that you have reviewed OWL's Terms of Service, Privacy Policy and consent to tele-health agreements found at the bottom of https://onlineweightloss.clinic
Submit
Should be Empty: