First Name
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Last Name
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Email
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Phone Number
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How Can We Help You?
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Please Select
Medical Weight Loss
Men's Health
Anti-Aging
General Inquiry (Please specify)
General Inquiry Please specify
General Information
Your Height
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Your Age
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Your Current Weight
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Sex Assigned at Birth
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Have you received any prior treatment for this concern?
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Yes
No
specify the treatment received
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Do you have any pre-existing medical conditions?
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Yes
No
specify details
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Are you currently taking any medications or supplements?
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Yes
No
specify name, dosage, and frequency
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Do you have any allergies, including medication allergies?
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Yes
No
list all known allergies
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Have you ever undergone any hormone therapy or testosterone replacement therapy (TRT)?
Yes
No
specify details
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Men's Health
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Erectile Dysfunction (ED)
Peptides
Nutrition
Exercise
ED
How long have you experienced symptoms of erectile dysfunction?
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Please Select
Less than 3 months
3-6 months
6 months - 1 year
More than a year
How often do you experience difficulty in achieving or maintaining an erection?
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Rarely
Sometimes
Frequently
Always
Do you experience nocturnal (nighttime) erections?
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Yes
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Have you noticed any decrease in sexual desire (libido)?
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Yes
No
Have you ever used any medications (e.g., Viagra, Cialis, Levitra) or treatments for ED?
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Yes
No
specify details and effectiveness
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Do you have any cardiovascular conditions (e.g., high blood pressure, heart disease)?
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Yes
No
specify details
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Do you suffer from diabetes or have abnormal blood sugar levels?
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Yes
No
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Do you smoke or use tobacco products?
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Yes
No
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How often do you consume alcohol?
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Never
Occasionally
Frequently
Daily
Have you experienced any recent stress, anxiety, or depression?
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Have you had any recent changes in weight, diet, or physical activity?
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Yes
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Do you have a history of prostate issues or prostate surgery?
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Yes
No
specify details
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Peptide Therapy
Are you interested in peptides for general health, muscle growth, fat loss, or recovery?
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General Health
Muscle Growth
Fat Loss
Recovery
Have you used peptide therapy before?
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Yes
No
specify type and effectiveness
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Do you have a history of hormone imbalances or low testosterone levels?
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Yes
No
specify details
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Do you have any history of growth hormone deficiencies?
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Yes
No
specify details
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Do you suffer from joint pain, injuries, or inflammation?
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Yes
No
specify details
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Are you currently on any hormone replacement therapy or supplements?
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Yes
No
specify details
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Do you engage in regular exercise or strength training?
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Yes
No
specify frequency and type of exercise
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Nutrition & Diet
What are your primary goals related to nutrition?
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Weight Loss
Muscle Gain
General Health
Other – Specify
Other – Specify
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How would you describe your current diet?
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Balanced
High Protein
High Carb
Low Carb
Vegan
Vegetarian
Other – Specify
Other – Specify
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Do you have any known food allergies or intolerances?
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Yes
No
specify details
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Do you follow any specific dietary restrictions?
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Yes
No
specify details
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Do you currently take any dietary supplements?
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Yes
No
specify name and purpose
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How many meals do you typically eat per day?
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Please Select
1
2
3
4
More than 4
Do you experience any digestive issues (bloating, acid reflux, IBS, etc.)?
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Yes
No
specify details
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Do you consume processed or fast food regularly?
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Yes
No
Do you consume alcohol, caffeine, or sugary drinks regularly?
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Yes
No
specify details
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Would you be interested in working with a nutritionist to optimize your diet?
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Yes
No
Exercise & Fitness
What are your primary fitness goals?
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Strength Building
Weight Loss
Endurance
General Health
Other – Specify
Other – Specify
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How often do you exercise per week?
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Never
1-2 times
3-4 times
5+ times
What type of workouts do you engage in?
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Weightlifting
Cardio
HIIT
Yoga
Pilates
Sports
Other – Specify
Other – Specify
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Do you have any past injuries or joint pain that limit physical activity?
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Yes
No
specify details
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Do you currently have a personal trainer or follow a structured program?
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Yes
No
specify details
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Do you have any medical conditions that affect your ability to exercise?
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Yes
No
specify details
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Are you interested in a personalized fitness plan?
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Yes
No
Lifestyle & Additional Information
How would you rate your current stress levels?
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Low
Moderate
High
Extreme
Do you experience difficulty sleeping or insomnia?
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Yes
No
Do you feel fatigued or low on energy during the day?
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Yes
No
Do you have a family history of hormonal disorders, cardiovascular disease, or diabetes?
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Yes
No
specify details
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Is there anything else you would like us to know regarding your health concerns?
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General Information Anti Aging
Your Height
*
Your Age
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Your Current Weight
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Sex Assigned at Birth
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What are your primary goals for anti-aging treatment?
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Please Select
Increased Energy
Improved Skin Health
Muscle Retention
Hormonal Balance
Overall Longevity
Other – Specify
Other – Specify
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Have you previously received any anti-aging treatments?
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Yes
No
specify treatment type and results
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Do you have any pre-existing medical conditions?
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Yes
No
specify details
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Are you currently taking any medications, supplements, or hormone therapy?
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Yes
No
specify details
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Do you have any known allergies, including medication allergies?
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Yes
No
list all known allergies
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Do you experience fatigue or low energy levels?
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Yes
No
how often and how severe?
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Have you experienced unexplained weight gain or difficulty losing weight?
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Yes
No
specify details
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Do you experience memory issues or brain fog?
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Yes
No
specify details
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Do you have a family history of age-related diseases such as osteoporosis, Alzheimer’s, or cardiovascular disease?
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Yes
No
specify details
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Anti-Aging
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Stem Cell Therapy
Hormone Optimization
Bioidentical Hormone Replacement Therapy (BHRT)
Aesthetic Therapy
Stem Cell Therapy
Are you interested in stem cell therapy for general wellness, anti-aging, joint pain, or chronic conditions?
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Please Select
General Wellness
Anti-Aging
Joint Pain
Chronic Conditions – Specify
Chronic Conditions – Specify
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Have you undergone any regenerative medicine treatments before?
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Yes
No
specify treatment and results
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Do you have any diagnosed degenerative conditions (arthritis, chronic inflammation, autoimmune disorders)?
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Yes
No
specify details
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Have you had any recent injuries or surgeries?
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Yes
No
specify details
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Do you currently have any cardiovascular or metabolic conditions?
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Yes
No
specify details
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Are you currently taking any blood thinners or immunosuppressive drugs?
Yes
No
specify details
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Do you have a history of chronic pain or mobility issues?
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Yes
No
specify details
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Would you like to schedule a consultation to learn more about stem cell therapy?
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Yes
No
Hormone Optimization
Have you had your hormone levels tested in the past year?
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Yes
No
specify details and results
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Do you experience any of the following symptoms? (Check all that apply)
*
Fatigue
Low Libido
Weight Gain
Mood Swings
Difficulty Sleeping
Reduced Muscle Mass
Hair Thinning
Other – Specify
Other - Specify
*
Have you ever been diagnosed with low testosterone or hormone imbalances?
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Yes
No
specify details
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Are you currently taking any hormone replacement therapy or supplements?
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Yes
No
specify name and dosage
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Do you experience difficulty recovering from exercise or prolonged soreness?
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Yes
No
Do you have any thyroid-related conditions?
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Yes
No
specify details
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Do you suffer from metabolic disorders (e.g., insulin resistance, diabetes)?
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Yes
No
specify details
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Have you noticed an increase in body fat despite maintaining the same lifestyle?
*
Yes
No
specify details
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Do you experience frequent mood swings, anxiety, or depression?
*
Yes
No
specify details
*
Would you like to book a hormone evaluation appointment?
*
Yes
No
Bioidentical Hormone Replacement Therapy
Are you currently on any form of hormone replacement therapy?
*
Yes
No
specify details and duration of treatment
*
Do you have any of the following symptoms of hormone imbalance? (Check all that apply)
*
Hot Flashes
Mood Swings
Fatigue
Memory Issues
Dry Skin
Reduced Libido
Difficulty Losing Weight
Other – Specify
Other – Specify
*
Have you undergone menopause or andropause (male menopause)?
*
Yes
No
specify details and age of onset
*
Do you have a history of breast, ovarian, prostate, or other hormone-related cancers?
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Yes
No
specify details
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Have you previously taken synthetic hormones?
*
Yes
No
specify type and duration
*
Are you interested in customized hormone therapy based on lab results?
*
Yes
No
Do you have any concerns about hormone therapy side effects?
*
Yes
No
specify concerns
*
Do you suffer from chronic fatigue, difficulty concentrating, or poor sleep quality?
*
Yes
No
specify details
*
Would you like to schedule a BHRT consultation?
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Yes
No
Aesthetic Therapy
What aesthetic treatments are you interested in?
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Please Select
Skin Rejuvenation
Wrinkle Reduction
Hair Restoration
Body Contouring
Other – Specify
Other – Specify
*
Have you had any cosmetic procedures or treatments before?
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Yes
No
specify details and results
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Do you have any skin conditions (e.g., acne, rosacea, hyperpigmentation)?
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Yes
No
specify details
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Are you currently using any skincare treatments or prescription skincare products?
*
Yes
No
specify details
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Do you have any history of allergic reactions to cosmetic treatments?
*
Yes
No
specify details
*
Are you pregnant, breastfeeding, or planning to become pregnant in the next 6 months?
*
Yes
No
Do you smoke or have a history of sun damage to the skin?
Yes
No
specify details
*
Are you looking for non-invasive or surgical aesthetic treatments?
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Please Select
Non-Invasive
Surgical
Not Sure – Need Consultation
Would you like a consultation to discuss aesthetic therapy options?
*
Yes
No
Lifestyle & Additional Information Anti Aging
How would you rate your current stress levels?
*
Please Select
Low
Moderate
High
Extreme
Do you experience difficulty sleeping or insomnia?
*
Yes
No
Do you feel fatigued or low on energy during the day?
*
Yes
No
Do you consume alcohol, caffeine, or sugary drinks regularly?
*
Yes
No
specify details
*
Do you have a family history of hormonal disorders, cardiovascular disease, or metabolic disorders?
*
Yes
No
specify details
*
Do you follow a structured fitness or wellness routine?
*
Yes
No
specify details
*
Are you interested in a customized anti-aging and wellness plan?
*
Yes
No
Is there anything else you would like us to know regarding your health concerns?
*
What do you want to accomplish with the Focus Medical Weight Loss Program?
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Your Height (in cm)
*
Your Age
*
Your Current Weight (in lbs)
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Sex Assigned at Birth
*
Are you currently pregnant, breastfeeding, or planning to become pregnant?
*
Which type of health insurance do you have?
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When did you first notice that you were gaining weight?
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Did you ever gain more than 20 pounds in less than 3 months?
*
When did you gain 20 pounds in less than 3 months?
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What was your maximum weight loss?
*
What are your greatest challenges with dieting?
*
Have you ever had weight loss surgery in the past?
*
Yes
No
Specify Type
*
Date
*
-
Month
-
Day
Year
Date
List any food intolerances/restrictions.
*
Food cravings and triggers
*
Favorite foods
*
Do you currently have, or have you ever been diagnosed with, any heart conditions?
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Do you have a history of hormone, kidney, or liver conditions?
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Do you have a history of gastrointestinal conditions?
*
Do you suffer from any irritable bowel diseases (e.g., Crohn’s disease, ulcerative colitis, IBS)?
*
Yes
No
Specify diagnosis and treatment
*
Have you ever been diagnosed with obstructive sleep apnea (OSA)?
*
Any history of osteoarthritis?
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List all allergies.
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Do you have an allergy to GLP-1 agonist medications?
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Medications, vitamins, dietary supplements currently taken.
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Smoking history
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Current
Past
Alcohol consumption and any prior treatment for alcoholism.
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Recreational drug use, including marijuana.
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Obesity history and other medical conditions.
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Additional medical history.
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Would You Like Us to Contact You to Book an Appointment?
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