Medical Weight Loss Program Evaluation
Front Porch Family Medicine LLC
Full Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
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Phone Number
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E-mail
example@example.com
How did you hear about us?
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What is your current weight and height?
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Do you have a personal or family history of medullary thyroid cancer or MEN 2 syndrome?
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Do you have a history of pancreatitis?
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No
Do you have current gallbladder problems?
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Yes
No
Are you taking insulin or sulfonylurea for diabetes (example: glimepiride, glipizide, or glyburide)?
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Yes
No
Are you suffering with uncontrolled depression or anxiety?
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Yes
No
How much alcohol do you drink, if any, each week?
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