Mapo Wellness Center, LLC New Patient Information and Consent Form
Mapo Wellness Center, LLC practices in a Non-Judgmental and Confidential Manner with all Patients. This form is not an attempt to provide specific medical advice, and it should not be used to make a diagnosis or to replace or overrule a qualified health care provider's judgment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.
Full Name
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First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile
*
E-mail
*
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Patient History
Height
Weight
Have You tried Weight Loss Interventions Before? IF so, Please List
Do you take regular medication?
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Yes
No
If Yes, please list
Do you have any pre-existing Health Conditions Mapo Wellness Center should be aware of?
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Yes
No
If Yes, please list
Do you suffer from any thyroid conditions?
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Yes
No
Do you have any known allergies to Medications or Foods?
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Yes
No
If yes please list
Do you regularly present with Symptoms of which you do not know the cause? If so, what are they?
*
Lifestyle
Do you believe your diet supports your Health?
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Yes
No
Over the last 3 days, what have you eaten?
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Be as specific as you can be
How many hours of sleep do you get?
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How often do you exercise?
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Everyday
5-6 Times per Week
2-4 Times per Week
Once per week
Never
Do you Smoke Tobacco?
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Yes
No
If Yes, How many per Day?
Do you drink Alcohol?
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Yes, Everyday
Yes, Often
Yes, Approx. Once Per Week
On Special Occasions
Never
Do you drink Caffeine?
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Yes
No
If Yes, How much?
Outcomes
What goals are you trying to achieve?
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What time frame have you given yourself to complete these Goals?
*
Consent
Please answer the following questions regarding consent
Consent to Mapo Wellness Center obtaining labs and lab results
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Allow
Do not Allow
Consent to Mapo Wellness Center administering GLP-1injections directly or indirectly
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Allow
Do not Allow
Consent to Mapo Wellness Center for being contacted via telephone, email, or telehealth
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Allow
Do not Allow
I Agree
*
I have read, understood, acknowledge and confirm that the above information is true and correct
Additional Information
If there is any other information you wish to make Mapo Wellness Center, LLC aware of please add here
Signature
*
Submit
Submit
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