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Lifestyle Questionnaire

Medical Weight Loss Intake Form

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Age(Required)

Phone Number(Required)

Email(Required)

Primary Care Provider(Required)

Primary Caregiver Phone Number(Required)

Medical History

Please select yes or no for each condition

Type 2 Diabetes(Required)

Prediabetes(Required)

High Blood Pressure(Required)

High Cholesterol(Required)

Heart Disease(Required)

Thyroid Disease(Required)

Pancreatitis(Required)

Gallbladder Disease(Required)

Kidney Disease(Required)

Liver Disease(Required)

Gastroparesis or chronic GI issues(Required)

Eating Disorder (current or past)(Required)

Depression or Anxiety(Required)

If YES to any above, please explain:(Required)

If none, type “none”

Family History

MEN2 (Multiple Endocrine Neoplasia Type 2)(Required)

Medullary Thyroid Cancer(Required)

Surgical History

Have you had any surgeries?(Required)

If YES, please explain:(Required)

If none, type “none”

Current Medications

Please list all prescription medications, over-the-counter medications, and supplements:(Required)

If none, type “none”

Allergies

List all allergies and your reaction(Required)

If none, type “none”

Weight & Health Information

Current Weight(Required)

Highest Adult Weight(Required)

Goal Weight

Have you previously tried weight loss medications?(Required)

If yes, which one(s) and what outcome?(Required)

If none, type “none”

Lifestyle Information

How would you describe your diet?(Required)

How often do you exercise?(Required)

Alcohol Use(Required)

Nicotine Use(Required)

If yes, what type?(Required)

If none, type “none”

Pregnancy & Hormonal Status (if applicable)

Are you currently pregnant?(Required)

Are you currently breastfeeding?(Required)

Are you planning pregnancy in the next 6 months?(Required)

Review of Symptoms (Check all that apply)(Required)

Nausea

Vomiting

Abdominal pain

Heartburn/Reflux

Constipation

Diarrhea

Fatigue

Dizziness

None of the above

Consent(Required)

• May cause side effects including nausea, vomiting, and GI discomfort
• Require lifestyle changes for best results
• Are part of a long-term treatment plan
• Will not be filed to insurance

I understand that GLP-1 medications:

I confirm that the information provided above is accurate to the best of my knowledge.

Signature(Required)

Date(Required)

Month

Day

Year

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Lifestyle Questionnaire

Medical Weight Loss Intake Form

Medical History

Family History

Surgical History

Current Medications

Allergies

Weight & Health Information

Lifestyle Information

Pregnancy & Hormonal Status (if applicable)

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