Weight Management Medical History Form (2026)
Consultation Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
How did you hear about us
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Date of Birth
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Month
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Day
Year
Date
Age
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Gender
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Male
Female
Height
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Weight
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Phone
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Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Occupation
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Drivers License
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State Issued
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Exp
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Upload State ID/Drivers License
*
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of
Treatment Goals
1. What is your primary goal for starting Semaglutide / Tirzepatide / Retatrutide / Orfoglipron?
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2. Have you tried weight-loss programs or medications before?
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3. Are you currently taking any medication or supplement for weight management?
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4. What motivates you to lose weight at this time?
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5. How long has weight been a concern for you?
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6. Are you currently at your heaviest weight? If not, what was your highest weight?
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7. My worst food habit is:
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Are you a stress eater?
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Yes
No
Eat at night?
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Yes
No
Partner struggles with weight?
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Yes
No
Are you scared of needles/needle phobic/faint easily when you have blood taken?
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Yes
No
Women Only
Date of last menstrual period
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Month
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Day
Year
Date
Check if any apply:
Are you trying for pregnancy or planning pregnancy in the near future?
Are you or could be pregnant?
Are you on any type of hormone replacement therapy?
Are you on any contraceptive methods?
Current Medications & Supplements
Prescription medications:
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Vitamins/Supplements:
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Date of last physical exam:
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Month
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Day
Year
Date
Last lab work:
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Attach recent lab work
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Any imaging tests in last 2 years?
Hospitalizations, Surgeries (Dates & Reasons)
Allergies (Drug, Food or Environmental)
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Laboratory Testing Consent
I understand and agree that laboratory testing is required prior to or during treatment as recommended by my provider.
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Please Select
YES
NO
I decline laboratory testing at this time (opt out). I understand that by opting out, my provider may not be able to safely prescribe or adjust medication, and I accept full responsibility for any risks or limitations of treatment without labs.
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Please Select
YES
NO
Patient Signature
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Date
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Month
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Day
Year
Date
Social History
Do you currently smoke or vape?
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Yes
No
Weekly alcohol intake:
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Caffeine intake:
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Exercise routine: (Type & Frequency):
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Recreational drug use? If yes details:
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Bowel Habits & GI Health
Daily Bowel movement frequency:
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Daily
Every 2-3 days
Less than 3x/week
Consistency:
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Normal
Loose
Alternating
History of constipation/IBS/gastroparesis/bowel obstruction?
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Yes
No
Bloating or Reflex?
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Yes
No
Current bowel support methods:
Past & Current Medical History
Check all that apply:
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Type 2 Diabetes
Pre-diabetes
High Cholesterol
High Blood Pressure
Liver Disease
PCOS
Heart Disease
Kidney Disease
Thyroid Disorder
Gallbladder Disease
Pancreatitis
GERD
Sleep Apnea
Depression/Anxiety
Eating Disorder
Osteoarthritis
Bariatric Surgery
Cancer
Mental health problems (including personality disorder, psychosis)
Self-diagnosis of depression, low mood, nervous or emotional problems
Substance abuse (including alcohol or drugs)
None
Other
Family History
Have you or your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)? Check those questions to which you answer: YES
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Medullary thyroid cancer
Multiple endocrine neoplasia 2A or 2B
None
Additional Notes
Patient Signature
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Date
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Month
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Day
Year
Date
Provider Signature
Date
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Month
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Day
Year
Date
Submit
Should be Empty: