Medical Weight Loss Patient Intake Questionnaire

Medical Weight Loss Patient Intake Questionnaire

Complete this form to provide your health information for weight loss assessment.
Personal Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical History
Do you have any of the following medical conditions?

Other
How long have you been struggling with weight?
Have you tried weight loss medications before?
If yes, which ones?
Are you currently pregnant or breastfeeding?
Current Medications (please list all)
Do you have any allergies?
Current Health & Weight Status
Current Weight (lbs)
Height (inches)
What is your weight loss goal?
Lifestyle & Habits
How would you describe your current diet?

Other
How often do you exercise per week?
How many hours of sleep do you get per night on average?
Consent & Acknowledgment
Consent Acknowledgments
Signature
Should be Empty: