Name
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First Name
Last Name
Email
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Phone
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(###)
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Preferred method of contact:
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Date of Birth
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Gender
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Height
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Current Weight
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Goal Weight
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Do you have any of the following conditions? (Check all that apply)
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Have you had any surgeries related to weight loss (e.g., gastric bypass, sleeve gastrectomy) or other gastrointestinal surgeries?
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If yes, please specify:
Do you have any known food allergies or medication allergies?
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If yes, please list:
List all medications and supplements you are currently taking (including over-the-counter, vitamins, and herbal supplements):
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Are you currently taking or have you previously used any weight loss medications (prescription or OTC)?
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If yes, which ones and what were the results?
What weight loss methods have you tried in the past? (Check all that apply)
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Other:
On a scale of 1 to 5, how would you rate your current eating habits? (1 = Poor, 5 = Very Healthy)
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1
2
3
4
5
Do you consume alcohol?
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If yes, how often?
How many meals/snacks do your eat per day?
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Have you ever had pancreatitis or been told you are at risk for it?
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Do you have a history of severe nausea, vomiting, or gastrointestinal issues?
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Do you have difficulty controlling low blood sugar (hypoglycemia)?
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Are you willing to commit to regular follow-up visits to monitor progress and adjust treatment if needed?
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I confirm that the information provided above is accurate to the best of my knowledge. I understand that weight loss treatments, including GLP-1 medications, require monitoring and lifestyle changes for effectiveness.
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