Medical Weight loss Screening
Thank you for joining us on a journey to whole body wellness. This questionnaire is designed to help Dr. Mitchell better understand your health history. If there are any questions you do not know the answer to or do not feel comfortable answering, please leave them blank. Contact our office at 719-238-6664 with questions or concerns.
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Age
Current Height
Current Weight
in pounds
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
How do you prefer to be contacted?
*
Phone
Email
Other
Screening Questions
Do you have a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2?
Yes
No
Have you previously used injectable weight loss medications before?
Yes
No
If you answered yes above, please elaborate (eg. medication name, dose, side effects, weight loss effects, ect.)
Have you ever been diagnosed with, or suffered from hypoglycemia?
Yes
No
Have you ever been diagnosed with, or suffered from Constipation, Gastroparesis, delayed gastric emptying, or GERD?
Yes
No
Have you ever been diagnosed with, or suffered from Hyperemesis Gravidarum otherwise known as morning sickness?
Yes
No
Are you pregnant or nursing?
Yes
No
Do you plan to become pregnant while participating in the weight loss program?
Yes
No
This questionnaire is designed specifically to screen medical weight loss patients, I understand this does not constitute a doctor patient relationship.
*
Yes
No
Thanks for taking the time to complete this screening.
Submit
Should be Empty: