Weight Loss Intake Form-Existing Patient

Patient Name

First NameLast Name

Patient Birth Date

MonthDayYear

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address has changed since last visit

If address has changed, please list it here:

What brand name medication are you on?

What dose are you currently on

How many doses have you received at this dose

Patient Height (inches)

Patient Weight (lbs)

Allergies

If you have allergies, please list them here

No changes from last visit

What are your weight loss goals?

Have you ever had (Please check all that apply)

Other illnesses:

Please list your Current Medications

Exercise

Eating following a diet

Alcohol Consumption

Caffeine Consumption

Do you smoke?

Black box warning summary: Prescription weight loss injections may carry serious risks and side effects, including potential severe gastrointestinal symptoms (such as nausea, vomiting, diarrhea, and abdominal pain), dehydration, acute kidney injury, gallbladder disease, pancreatitis, and possible worsening of diabetic retinopathy. In some patients, these medications may also increase the risk of thyroid C-cell tumors; they should not be used in people with a personal or family history of medullary thyroid carcinoma or MEN2. These medications may also delay gastric emptying, which can affect tolerance of food and oral medications, and may contribute to hypoglycemia when used with other glucose-lowering drugs. Review all risks, warnings, benefits, and precautions with a qualified clinician before starting treatment.

Consent summary: By proceeding, you acknowledge review of the medication risks, understand the treatment expectations, and agree to discuss any questions before starting therapy.

Patient Signature - I have been informed of risks/benefits/side effects/black box warnings regarding GLP medications

I have been offered a quiet and private office to discuss my medical health but choose to discuss this in a support group environment at the weight loss group therapy room

Patient Signature

Patient Signature Date

Date

Provider signature

Provider signature date

Date

HPI / ROS / Physical Examination

HPI:
Patient presents to establish care for medically supervised weight management. Reports difficulty achieving and maintaining weight loss despite previous attempts with diet modification, exercise, and lifestyle changes. States excess weight has negatively affected overall health and quality of life. Patient is motivated to improve weight, overall wellness, and reduce obesity-related health risks. Weight history, current medications, allergies, past medical history, family history, and lifestyle habits reviewed. Risks, benefits, alternatives, potential side effects, and expectations of GLP-1 therapy discussed. Patient verbalizes understanding and wishes to proceed if medically appropriate. Baseline labs and individualized treatment plan reviewed as indicated.
Review of Systems (ROS):
Constitutional: Reports difficulty with weight management. Denies fever, chills, or unexplained weight loss.
HEENT: Denies headache, vision changes, or difficulty swallowing.
Cardiovascular: Denies chest pain, palpitations, or edema.
Respiratory: Denies cough or shortness of breath.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or blood in stool.
Genitourinary: Denies dysuria or urinary complaints.
Musculoskeletal: Denies acute joint swelling or muscle weakness.
Neurologic: Denies dizziness, syncope, numbness, or focal weakness.
Psychiatric: Denies depression, anxiety, suicidal ideation, or homicidal ideation.
Endocrine: Reports difficulty losing weight. Denies heat/cold intolerance or excessive thirst.
Skin: Denies rash or concerning skin lesions.
Physical Examination:
General: Alert, oriented ×3, well-developed, well-nourished, in no acute distress.
Vital Signs: Reviewed and documented.
HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light. Mucous membranes moist.
Neck: Supple without thyromegaly or lymphadenopathy.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.
Respiratory: Lungs clear to auscultation bilaterally. No respiratory distress.
Abdomen: Soft, non-tender, non-distended. Bowel sounds present.
Extremities: No cyanosis or edema.
Musculoskeletal: Normal gait. Full range of motion.
Neurologic: Cranial nerves II-XII grossly intact. No focal neurologic deficits.
Skin: Warm, dry, intact. No rashes noted.
Psychiatric: Appropriate mood and affect. Normal judgment and insight.

Weight Loss Intake Form

Healthy & Unhealthy Habits