Weight Loss Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age
*
Sex
*
Male
Female
Weight
*
Height
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
In case of emergency, please contact:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Allergies
*
(Please check all that apply)
*
Personal or family history of Medullary Thyroid Cancer (MTC)
Multiple Endocrine Neoplasia Type 2 (MEN2)
Thyroid related conditions
History of Pancreatitis
Type 1 Diabetes
Blood pressure problems (High or low)
Stroke or “mini-stroke”
Autoimmune Condition(s)
Cancer
N/A
Other
Do you take any type of Insulin? If so, please list:
*
Do you have any Heart Problems? If so, what type?
*
Are you currently taking any GLP-1 agonists listed below?
*
Dulaglutide (Trulicity)
Exenatide extended release (Bydureon)
Exenatide (Byetta)
Semaglutide (Ozempic or Wegovy)
Semaglutide (Rybelsus)
Liraglutide (Victoza, Saxenda)
Lixisenatide (Adlyxin)
Tirzepatide (Mounjaro)
N/A
Are you currently taking a Sulfonylurea listed below?
*
Diabeta, Glynase or Micronase (Glyburide or Glibenclamide)
Amaryl (Glimepiride)
Diabinese (Chlorpropamide)
Glucotrol (Glipizide)
Tolinase (tolazamide)
Tolbutamide
N/A
Do you have any kidney impairments?
*
Have you ever been diagnosed with an eating disorder?
*
Do you take any medications that are designed to reduce appetite or prescribed any medications to aid in weight loss or weight gain?
*
Do you suffer from delayed gastric emptying or gastroparesis?
*
Prescription Medications – Strength – Frequency
*
Over the Counter Drugs – Strength – Frequency
*
Vitamins and Other Supplements – Strength – Frequency
*
List any other medical conditions you have (not mentioned above):
*
List of all surgical procedures you’ve had with approximate dates:
*
Is there anything else you’d like the physician to know?
*
Submit
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