Weight Loss New Patient Form

  • Weight Loss New Patient Intake

    Please complete all sections accurately to help us provide you with the best care.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • How did you hear about Vitality Hormones & IV Bar?*
  • Has your doctor ever said your blood pressure was too high or too low?*
  • Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*
  • Has your doctor ever told you that your cholesterol was too high?*
  • Have you (or a family member) ever been told that you have diabetes?*
  • Have you ever been diagnosed with an autoimmune condition?*
  • Have you ever been diagnosed or treated for a Thyroid condition?*
  • Do you have any injuries or orthopedic problems (back, knees, etc)?*
  • Do you have stiff or swollen joints?*
  • Do you have tension or soreness in any area?*
  • Are you allergic to any medication or food?*
  • Are you taking any prescribed medications or dietary supplementation?*
  • Have you been on hormone replacement therapy in the past?*
  • Do you ever have problems sleeping?*
  • Have you used weight loss medications in the past?*
  • Have you used a specific diet in the past to help you lose weight?*
  • Are you currently breast feeding?*
  • Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?*
  • Symptoms (check all that apply)*
  • Lab Payment Option*
  • Date*
     - -
  • Should be Empty: