Weight Loss Consultation Form

Weight Loss Consultation Form

Our weight loss consultation form is a tool that facilitates a more effective, safe, and personalized approach to achieving your weight loss goals, while also ensuring your health and well-being are prioritized.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.
Past Programs and Current Weight Loss Goals
Patient Height (inches)*
Patient Weight (lbs)*
What are your weight loss goals?*
Previous Use of Weight Loss Medications:

PhentermineMetforminTopiramate (Topamax)Wellbutrin (bupropion)Qsymia (Phentermine/Topiramate)Contrave (naltrexone/bupropion)Belviq (lorcaserin)Saxenda/Victoza (liraglutide)Semaglutide (GLP-1)SGLT-2 inhibitorTirzepatideOther
Motivations and Goals
What is your main reason for obesity treatment?

I want this for myself (“self-motivation”)A family member insisted that I lose weight.My physician has recommended weight loss.Other
What is your motivation for obesity treatment?

To improved appearanceTo be more activeTo have a better quality of lifeTo improve in my health conditions.Other
What treatments are you interested in pursuing?

Lifestyle changes onlyLifestyle changes and weight loss medicationsI’m open to surgical weight loss
Overall Goals:

No weight goal, only to feel betterNo weight goal, improvement in __________________________Weight goal of ___________ lb
Patient Medical History
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaOther
Other illnesses:
Please list any drug allergies
Please list your Current Medications
Healthy & Unhealthy Habits
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the medical office of any changes in my medical status.
Should be Empty:

Weight Loss Consultation Form

Past Programs and Current Weight Loss Goals

Motivations and Goals

Patient Medical History

Healthy & Unhealthy Habits