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
Date
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
DiabetesHypertension (High Blood Pressure)Thyroid DisordersHeart DiseaseSleep ApneaNoneKidney DiseasePancreatitisOther
How long have you been struggling with weight?
YesNo
If yes, which ones?
YesNo
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
HealthyModeratePoorOther
How often do you exercise per week?
How many hours of sleep do you get per night on average?
Consent & Acknowledgment
I confirm all information provided is accurateI understand this is a medical evaluation and does not guarantee a prescriptionI agree to the Terms of Service and Privacy Policy
Signature*
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