Ever Align Medical Weight Loss Intake Form

Ever Align Medical Weight Loss Intake Form

Fill out our brief interest form, and our team will reach out to schedule your complimentary consultation with our Medical Director.
Please answer all questions honestly, and as best you can.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Phone Number*
For follow-up purposes onlyFormat: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Are you a current/returning client for Ever IV?*

YesNo
What is your height?*
What is your current weight?*
In the past 2 years, what was your maximum weight?*
What best describes the trajectory of your weight?*

Increasing slowly for yearsIncreasing more quickly than in the pastIncreased quickly after a lifestyle change and is now "stuck" thereHas remained stubbornly stable yearsDecreasing, but very slowly and with much effortInitially decreased with diet/exercise, but has since plateaued (or is going back up)Decreasing well on weight loss medication prescribed by another providerOther
How much do you agree with the following statement: "I've tried to manage my weight using various diet and exercise plans, but none have provided satisfactory long-term results."*

Strongly disagreeDisagreeNeutralAgreeStrongly Agree
Have you ever had any of the following? (select all that apply)*

Multiple endocrine neoplasia type 2 (MEN2)Serious allergic reaction to Zepbound, Mounjaro or compounded tirzepatideSerious allergic reaction to Ozempic, Wegovy or compounded semaglutideMedullary thyroid cancerNone of these
Has anyone in your family ever had medullary thyroid cancer (MTC)? (Note: MTC is not the same as papillary, follicular or anaplastic thyroid cancers)*

YesNoSomeone in my family had thryoid cancer, but I'm not sure which type
Have you ever had any of the following? (select all that apply)*

Type 1 diabetesDiabetic retinopathyBariatric surgeryGastroperesisMalabsorptionStomach diseaseKidney diseaseGallbladder diseasePancreatic diseaseNone of these
Do you identify with any of the following statements?(select all that apply)*

I've recently lost 14 lbs or more during a 3 month periodI sometimes make myself throw up because I've become too fullThoughts or fears about my weight often dominate my lifeOther people say I'm too thin, but I think they're wrongOne or more members of my family have suffered from an eating disorderI have suffered from an eating disorderNone of these
Are you scheduled to have any surgeries or procedures that require anesthesia or deep sedation?*

YesNoNot currently, but possibly in the next year
How would you describe your reproductive status?*

Currently pregnantPlanning to become pregnantCurrently breastfeedingTaking oral birth control pillsOn another form of birth controlI do not have to worry about becoming pregnantI am a biological maleOther
Are you currently taking any of the following medications?(select all that apply)*

InsulinSulfonyureals (ex: glipizide, glimepiride, glyburide)Semaglutide (ex: Ozempic, Wegovy)Tirzepatide (ex: Zepbound, Mounjaro)None of these
Do you have any of the following weight-related medical conditions?(select all that apply)*

Type 2 diabetesPre-diabetesCardiovascular diseaseFatty liver diseaseMetabolic syndromePolycystic ovarian syndromeObstructive sleep apneaHigh blood pressureHigh cholesterolHigh triglyceridesGoutNone of these
Have you developed any of the following symptoms as a result of gaining weight?(select all that apply)*

Loud snoring that disrupts self or partnerJoint pain that impairs mobilityAcid reflux or heart burnDisproportionately increased waist sizeImpairment in mood or self-esteemNone of these
Besides those you have already identified in the previous questions, are there any other medical conditions you are currently managing?
Which of the following best describes you?*

I rarely ever think about foodThe amount I think about food feels normal and healthyI think about food more than most people, but it doesn't bother meI wish I didn't think about food as often as I doI have constant intrusive thoughts about food that significantly disrupt my lifeOther
Do you identify with any of the following statements?(select all that apply)*

I often continue eating even when I'm no longer hungryI sometimes feel like I have no control over my own eatingI have intermittent episodes of excessive overeatingMy episodes of overeating cause me to feel shame, guilt or embarrassmentNone of these
Do you identify with any of the following statements?(select all that apply)*

My diet is very disciplined during the week, but it falls apart on the weekendsMy diet is much more healthy when I eat alone than when I eat with othersI sometimes feel social pressure to eat even when I'm not hungryIt's hard for me to control what I eat when I'm upset or stressedIt's hard for me to control what I eat when I'm in a celebratory moodNone of these
Do you identify with any of the following statements?(select all that apply)*

I eat a lot more than I normally would when I'm drinking alcoholMy alcohol consumption mirrors my eating: once I start, it's hard to stopThe amount I think about drinking alcohol bothers meI sometimes don't feel fully in control of my alcohol consumptionDrinking alcohol is interfering with my diet and exercise goalsWhile I'm not looking to fully abstain from alcohol, I would like to cut backNone of theseOther
Are there any other ways in which your weight or eating patterns have negatively impacted your life?*
Are you hoping to have your prescription insurance cover the medication costs of this program?

Yes, and my participation in the program is dependent on thisYes, but if the meds are not covered I can pay out of pocketMaybeNo, I will be paying out of pocket for the meds
Are you hoping to use a Health Savings Account (HSA) or Flexible Spending Account (FSA) to reimburse you for this program?

Yes, but only for the cost of the medicationsYes, but only for the cost of the care provided by the medical providersYes, for both costsMaybeNoOther
If there is anything additional you would like us to know ahead of your consultation, let us know below. Thank you!
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