IMHS Medical Weight Loss Patient Intake

IMHS Medical Weight Loss Patient Intake

Innovative Men’s Health | Bellevue, WA | (425) 455-1700 | innovativehealthsolutions.net — Please complete this intake so our clinical team can understand your health history, weight-loss experience, current medications, and treatment goals. A licensed provider will review your information to determine whether medical weight-loss treatment may be appropriate. Submission does not guarantee treatment or a prescription. We’ll contact you about required labs, consultation, and next steps.
Patient Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Biological Sex
Age
Last 4 of National ID
Marital Status
Street Address
Address Line 2
City
State/Province
ZIP Code
Primary Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Occupation / Employer
Emergency Contact
Emergency Contact Full Name

First NameMiddle NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral and Weight-Loss Goals
How did you hear about Innovative Men's Health?
Primary reasons for seeking weight loss / GLP therapy

Other
Main weight-loss and health goals
Primary State of Residence
Current and Past Medical History
Medical conditions
Details on selected conditions
Allergies
Drug/Medication Allergies and Reaction Type
Other Allergies (Food, Latex, Environmental)
Current Medications and Supplements
Current prescription medications
Vitamins, supplements, peptides, and over-the-counter products taken regularly
Weight History and Prior Weight-Loss Attempts
Current Weight (lbs)
Goal Weight (lbs)
Highest Adult Weight (lbs)
Lowest Adult Weight (lbs)
Height
Age first struggled with weight
How long have you been actively trying to lose weight?
Previous methods tried
Prior GLP-1 or weight-loss medications
What worked best and what was most difficult
Prior Hormone / Anabolic / Performance Use
Prior hormone, anabolic, or performance-enhancing use
Details (what, dose, duration, and when stopped)
Current Symptom and Goal Severity
Constant hunger / food noise

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Strong cravings, especially sweets/carbs

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Low energy / fatigue

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Low motivation for exercise

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Poor sleep quality

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Joint pain related to weight

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Mood / irritability related to weight

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Body image / self-confidence concerns

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Severe
Lifestyle and Body Metrics
Height (inches)
Current Weight (lb)
Goal Weight (lb)
Waist Circumference (inches)
Typical Blood Pressure (if known)
Exercise Days per Week
Exercise Types / Details
Average Sleep Hours per Night
Sleep Quality
Snore or Stop Breathing at Night?
Approximate Alcoholic Drinks per Week
Tobacco / Nicotine / Vape Use
Cannabis / THC Use
Other Substances
Daily Stress Level
Typical Diet / Nutrition, Problem Foods, etc.
Family Medical History
Family medical history conditions
Additional family history details
Recent Laboratory Results
Relevant labs in the past 12 months?
Approximate date and recalled values (e.g., A1c, fasting glucose, lipids, total/free testosterone)
Comprehensive baseline labs such as A1c, CMP, CBC, lipids, and hormone panel as indicated are typically ordered before starting GLP therapy.
Other Providers and Pharmacy
Primary Care Physician Name

First NameLast Name
Primary Care Clinic / Phone
Preferred Pharmacy Name
Preferred Pharmacy Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Specialists Seen Regularly
Acknowledgments and Consents
Information provided is true, complete, and accurate
Consent to telehealth evaluation, consultation, and treatment when appropriate
Acknowledgment of Notice of Privacy Practices and consent to use/disclosure of PHI for treatment, payment, and healthcare operations
Agreement to baseline and ongoing laboratory testing
Understanding of potential GLP-1 risks and side effects
Understanding that certain conditions, including personal/family history of medullary thyroid carcinoma, MEN2, prior pancreatitis, or severe gastroparesis, may be contraindications and must be disclosed
Agreement to recommended follow-up, monitoring, and communication
Understanding that services may be cash-pay/self-pay and insurance coverage is not guaranteed
Opportunity to ask questions and right to decline treatment
Agreement to provide government-issued photo identification for telehealth prescribing and medical records
Patient Signature / Attestation
Electronic Signature Attestation
Patient Full Legal Name / Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Should be Empty:

IMHS Medical Weight Loss Patient Intake

Patient Information

Emergency Contact

Referral and Weight-Loss Goals

Current and Past Medical History

Allergies

Current Medications and Supplements

Weight History and Prior Weight-Loss Attempts

Prior Hormone / Anabolic / Performance Use

Current Symptom and Goal Severity

Lifestyle and Body Metrics

Family Medical History

Recent Laboratory Results

Other Providers and Pharmacy

Acknowledgments and Consents

Patient Signature / Attestation