Weight Loss Program Intake Form

Weight Loss Program Intake Form
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Method of Communication: *
Gender: *
Do you have any allergies?*

YesNo
If Yes, please list:
How did you hear about this program?
What weight loss medication are you interested in? *
Please enter your height and weight to calculate BMI. Patients with a BMI under 23 are not eligible for treatment.
Current Weight:*
Height:*
Format Example: 5'3
Medical History
What are your primary concerns and goals when it comes to your weight and overall wellness?*
Are you currently participating in any weight management program or following a specific diet?*

YesNo
If Yes, please explain:
Do you exercise regulary?*
Do you smoke Tobacco?*
Do you consume alcohol?*
Do you take any medication, birth control, vitamins, or herbal supplements?*

YesNo
If Yes, please list:
Female Patients - Are you currently:*

Not PregnantPregnantTrying to get PregnantBreast FeedingPost Menopausal
Medical History

Do you currently have or have you had any of the following Health Conditions? (Check all that apply): *

Rows	No	Yes
Diabetes (Type 1 / Type 2 / Prediabetes)
Thyroid disorders (Hypothyroidism, Hyperthyroidism)
Kidney disease (Chronic kidney disease, Kidney stones)
Gallbladder disease or history of gallstones
Gastrointestinal disorders (GERD, IBS, Gastroparesis)
Pancreatitis or pancreatic disease
Liver disease (Fatty liver, Cirrhosis, Hepatitis)
Cancer (current or history of any type, including thyroid cancer)
Mental health conditions (Anxiety, Depression, Eating disorders)
Hormonal disorders (PCOS, Menopause-related issues)
Neurological conditions (Migraines, Seizures, Neuropathy)
Autoimmune disorders (Lupus, Rheumatoid arthritis, Multiple sclerosis)
Heart disease (Heart attack, Arrhythmia, High blood pressure)

Have you ever had weight loss surgery?*

YesNo
If Yes, date of procedure:
Are you currently under the care of a Physician?*

YesNo
If Yes, please name of provider and contact Info::*
What is your ideal weight?*
How long has weight been an issue?*
What is your heaviest weight?*
What is your current weight?*
What do you feel are the main contributors to having excess weight? (Check all that apply):*

Child BirthSleep IssuesStessFamily HistoryHormone ChangesExcessive SnackingAlcohol IntakeMedical ConditionLate Night EaterBusy LifestyleEmotional EaterMenopause
Do you experience any potential weight loss obstacles below? (Check all that apply):*

Skipping MealsBinge EatingStess EatingFamily HistoryHormone ChangesExcessive SnackingPsychological FactorsUnsupportive PartnerNone of the above
What methods have you used in the past for weight loss?*

ExerciseDiet ModificationsPrescription MedicationsWeight Loss PillsTherapyInjections
Intake & Processing Fee

A $35 non-refundable processing fee is required to begin your intake. This fee covers a comprehensive review of your information by a Registered Nurse, who will then collaborate with our Medical Director to determine your eligibility for treatment. Once your intake has been submitted, a member of our licensed staff will reach out to collect the $35 processing fee and guide you through the next steps
Signature*
Date

MonthDayYear
Date
Should be Empty:

Medical History