Patient Information
Full Name
*
Phone
*
Email
*
Birthdate
*
Gender
*
Select an option
Address
*
Street Address
City
State
Country
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Postal Code
Emergency Contact Name
*
Emergency Contact Phone
*
Primary Care Provider
Primary Care Provider Phone
HEIGHT / WEIGHT INFORMATION
Height (ft)
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Height- foot
Height (in)
Select
Height- inches
Enter
Enter current weight
Waist Size
Enter waist size here
Goal Weight
enter your goal weight here
BMI %
Current BMI
Weight Loss History
How long have you struggled with weight loss concerns?
What methods have you used to lose weight before?
What worked best for you in the past?
Previous Diet Programs
Exercise Programs
Prescription Weight Loss Medications
GLP-1 Medications
Personal Trainer
Bariatric Surgery
Fasting / Keto / Low Carb
Supplements
Other
None
Select all that apply
Biggest challenges with weight loss
Hunger / Cravings
Portion Control
Emotional Eating
Lack of Energy
Slow Metabolism
Hormonal Issues
Limited Activity
Stress
Other
None
Select all that apply
Current Medical History
Please check any condition you currently have or have had previously:
High Blood Pressure
Diabetes / Prediabetes
High Cholesterol
Heart Disease
Stroke / TIA
Sleep Apnea
Thyroid Disorder
GERD / Acid Reflux
Gallbladder Disease
Pancreatitis
Kidney Disease
Liver Disease
Depression / Anxiety
Eating Disorder
PCOS
Chronic Pain
Cancer
Constipation
Migraine Headaches
Other
GLP-1 SCREENING QUESTIONS
Have you ever used a GLP-1 medication before?
Yes
No
If so, which?
Semaglutide
Tirzepatide
Liraglutide
Ozempic
Wegovy
Mounjaro
Zepbound
Other
Did you experience side effects?
Yes
No
Which Side Effects (if any)
Nausea
Constipation
Vomiting
Diarrhea
Fatigue
Heartburn
Injection Site Reactions
Other
Any history of-
Medullary Thyroid Cancer
MEN-2 Syndrome
Pancreatitis
Severe Gastroparesis
None
If any of the above are checked, a consultation is required.
Are you currently pregnant or breastfeeding?
Yes
No
CURRENT MEDICATIONS
List current medications here.
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