Medical Weight Loss Consultation Intake
Thank you for your interest in our medical weight loss program. Please complete this form prior to your consultation. Completion of this form does not guarantee treatment. Final eligibility will be determined after provider evaluation. Target completion time: 5–10 minutes.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Text Message
Current Health Information
Height
*
Current Weight
*
Goal Weight
Primary Weight Loss Goal
*
Weight Loss
Appetite Control
Weight Maintenance
Improved Energy
Overall Health Improvement
Other
Medical Screening
Are you currently pregnant or breastfeeding?
*
Yes
No
Have you ever had pancreatitis?
*
Yes
No
Have you ever had gallbladder disease?
*
Yes
No
Do you have diabetes?
*
Yes
No
Do you have kidney disease?
*
Yes
No
Do you have liver disease?
*
Yes
No
Have you ever been diagnosed with gastroparesis or delayed stomach emptying?
*
Yes
No
Do you have a personal or family history of medullary thyroid cancer?
*
Yes
No
Have you ever been diagnosed with MEN2 syndrome?
*
Yes
No
Medication History
Current Medications
Current Supplements
Allergies
Previous Weight Loss Treatment
Have you previously used semaglutide?
*
Yes
No
Have you previously used tirzepatide?
*
Yes
No
Have you previously used another weight loss medication?
*
Yes
No
If yes, please describe your experience with prior weight loss treatments
Lifestyle Snapshot
How many days per week do you exercise?
*
Please Select
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
How many hours of sleep do you typically get per night?
*
How much water do you drink daily?
*
Please Select
Less than 1 liter
1–2 liters
2–3 liters
More than 3 liters
What is your biggest challenge with weight loss?
*
Safety Questions
Have you had recent abdominal pain?
*
Yes
No
Have you had recent nausea or vomiting?
*
Yes
No
Have you had recent constipation?
*
Yes
No
Have you had recent diarrhea?
*
Yes
No
Do you have difficulty swallowing?
*
Yes
No
Do you have severe reflux or heartburn?
*
Yes
No
Have you had a recent emergency room visit?
*
Yes
No
Have you had a recent hospitalization?
*
Yes
No
Acknowledgment and Signature
Acknowledgment: This form does not guarantee treatment
*
I understand
Acknowledgment: Eligibility is determined by provider evaluation
*
I understand
Acknowledgment: The information provided is accurate to the best of my knowledge
*
I understand
Acknowledgment: Emergency medical concerns should be directed to 911 or emergency services
*
I understand
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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