REFCODE
Weight Loss Red Light Intake Form
PERSONAL INFORMATION
First Name
*
Last Name
*
Which location would you like to visit for Red Light?
*
St. Charles MO - (636) 410-5858
Shiloh IL - (618) 234-8300
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Marital Status
*
Single
Married
Separated
Divorced
Pregnant and/or breastfeeding?
*
Yes
No
Biologic Sex (assigned @ birth)
*
Male
Female
Height
*
Weight
*
Who can we thank for referring you to our office?
*
Friend/Family
Doctor
Search
Social Media
Email
N/A
Other
Name of family/friend who referred you?
*
Name of doctor who referred you?
*
Which search engine did you use?
*
Facebook, Instagram, TikTok or other?
*
MEDICAL HISTORY
Please check all that apply
*
Depression
Brain Fog
Headache
Heart Attack
Hypoglycemia
Poor Sleep
Diabetes
Anemia
Dizziness
Thyroid Disease
Cancer
Arthritis
Galbladder Issues
High Blood Pressure
Weight Gain
Kidney Disease
Intestinal Problems
Back Pain
Stroke
Shortness of Breath
Carpal Tunnel
Fatigue
High Cholesterol
Neuropathy
Nerve Pain
Disc Issues
Other
Is there a certain time of the day any of these problems are better or worse?
*
Type N/A if this doesn't apply
List medications and supplements
*
Include what you're taking the med/supplement for. Type N/A if none
Known Allergies?
*
If none, type N/A
Main Concerns: (type above each numbered line)
1
*
2
3
4
How long have these items bothered you?
*
How does this affect your body functions and/or quality of life?
*
What would improve if you didn't have this/these concerns?
*
Diminished Stress
Family
Confidence
Work
Self-Esteem
Sleep
More Energy
Outlook
Other
How have you addressed weight management in the past?
*
Meds
Vitamins
Exercise
Diet and Nutrition
Other
How have these methods worked for you?
*
Are there any potential barriers that may prevent you from achieving your goals?
*
Do you feel it's possible to eliminate or prevent these potential barriers?
*
What outcome would you like to see for this to be a success for you?
*
Please rate on a scale of 1-10 the following:
1=Lowest 10=Highest
Energy Level
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Sleep Quality
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
How important is it for you to resolve your health concerns?
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
How prepared are you to make necessary lifestyle changes to achieve your goals?
*
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
I am interested in:
*
Weight Loss
Anti-Aging
Long-Term Results
Inch Loss
Metabolism / Gut Health Support
Submit
Should be Empty: