Eternelle Health - **FINAL ** Intake Form

Medical History Form
Ambassador Name
Full Name

First NameLast Name
Birth Date

MonthDayYear
Date
What is your gender?
How did you hear about us?
Email Address
example@example.com
Contact Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.
Have you recently discontinued the use of a weight loss medication? If so, please tell us which brand, when you stopped using the medication and at what dose/strength did you stop?
Are you currently on a Semaglutide/Ozempic, Mounjaro, or any other weight loss medication and switching to us? If so, please tell us why and where you are currently at in the process.
Check the conditions that apply to you or any member of your immediate relatives:

CancerCardiac diseaseHigh Blood PressureHepatitisSeizure DisorderHIV/AIDSLeber's Optic NeuropathyHormone ImbalanceBlood ClottingSkin DiseaseDiabetesCurrent Infections /IllnessThyroid CancerGastrointestinal DiseaseNone of the AboveChronic pancreatitisHistory of Pancreatic CancerOther
If Yes, provide further information:
Check the symptoms that you' re currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
Do you have any of the following allergies:

Food/NutsLidocaineAspirinLatexHydrocortisoneShellfish/Animal ProteinNoneOther
How much weight are you looking to lose

0-10 LBS11-20 LBS21-30 LBS31-40 LBS41-50 LBS51-60 LBS61-80 LBSOther
Are you currently taking any medication?

YesNo
Can you please list the medications you are currently taking?*
Are you currently pregnant or trying to become pregnant?

YesNo
Are you breastfeeding?

YesNo
Current weight
Desired weight
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
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?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
By signing below, I have read, understand, and consent to the possible side effects. I agree to the terms listed about and authorize treatment.

Powered by Jotform SignClear
Bloodwork
Bloodwork is required for our physician to review. This is to protect YOU! If you have bloodwork within the last 90 days you can upload the results below. If you do not have bloodwork, we can set you up at a Quest Diagnostics near you.
File Upload

Cancelof
Should be Empty:

Medical History Form