HYDROH LAB Weight Loss Intake!

HYDROH LAB
Patient Name
DOB
Gender
Address
Phone
Treatment Requested
Todays Date

MonthDayYear
Date
*to be completed by the patient*
Current Weight
Goal Weight
When did you first become overweight? Age & Year
blanks & blank .
How long have you been overweight
How did your weight gain start
Describe your weight loss methods in the past:
Did they work? Why or why not?
Have you tried weight loss injections in the past?

YesNo
If yes, please describe when and what kind:
Are you currently under the care of a physician?

YesNo
If yes, for what?
Have you recently had blood work done?

YesNo
If yes, when?
Were there any abnormalities?

YesNo
If yes, please describe:
Do you currently have or previously have a history of any of the following ( Check all that apply)

DiabetesHepatitisHIVAnemiaThyroid problemsBleeding DisordersBlood clotsSeizuresHeart disease or ConditionAutoimmune DisorderCancerChemotherapy/RadiationGallbladder DiseasePancreatitisGastrointestinal Disease
If you selected any of the above please describe
Do you have a personal or family history of any of the following:
Medullary thyroid cancer

YesNo
Multiple endocrine neoplasia type 2 syndrome

YesNo
If you answered yes to any of the above please describe
Are you currently taking any of the following medications?
Insulin

YesNo
Sulfonylureas (such as glyburide, glipizide,glimepiride, and tolbutamide)

YesNo
Other weight loss injections (such asOzempic, Wegovy, Adlyxin, Byetta, Bydureon, Rybelsus,Trulicity, and Victoza)

YesNo
Blood thinners

YesNo
If you answered yes to any of the above please describe
Please list all medications prescription over the counter vitamins herbs and supplements you are currently using
Please list any allergies you have to medication food or metals
Are you currently pregnant or breastfeeding?

YesNo
Do you plan to become pregnant in the nextfew months?

YesNo
Do you smoke?

YesNo
Do you drink alcohol ?

YesNo
If yes, how many drinks per week?
Do you use recreational drugs?

YesNo
If yes, what kind and how often?
Please describe any other health history or concerns that you have that have not been addressed above
I, certify that the information provided by me in this form is accurate and correct to the best of my knowledge.
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HYDROH LAB

Do you have a personal or family history of any of the following: