Patient Intake FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthDate of VisitPrimary Care Physician & Preferred Pharmacy PCP Name (N/A if not applicable) *PCP PhonePCP FaxYears of Care (N/A if not applicable)Pharmacy Name *Pharmacy PhonePharmacy Location (City, State)Highest WeightInitial WeightLowest Weight Over the Past Few YearsGoal WeightPast Medical History: Please check all conditions that apply.CardiovascularCoronary Artery Disease (CAD)Hypertension (HTN)Cerebrovascular Accident (CVA)HyperlipidemiaPeripheral Arterial DiseaseCongestive Heart FailureCardiomyopathyMetabolicMetabolic SyndromeHypertriglyceridemiaPolycystic Ovarian Syndrome (PCOS)Abnormal Coronary Calcium ScoringPulmonaryObstructive Sleep Apnea (OSA)Chronic Obstructive Pulmonary Disease (COPD)GastrointestinalFatty Liver DiseaseNon-Alcoholic Steatohepatitis (NASH)Liver FibrosisMusculoskeletalDegenerative Joint Disease (DJD)Degenerative Disc Disease (DDD)Chronic Lower Back PainReproductive (female)InfertilityMale HypogonadismPsychologicalAnxietyDepressionPost-Traumatic Stress Disorder (PTSD)Bipolar DisorderGeneralBenign Raise in Intracranial PressureMigraineUrinary Stress IncontinenceChronic Kidney DiseasePast Surgical History: Surgery YearMedications, Supplements & Allergies: Please include all prescription medications, over-the-counter drugs, diabetic medications, vitamins, and dietary supplements.Name of Medication/Supplement Dosage Amount # Taken DailyOther Medications/Supplements:Any medication allergies?YesNo(If yes, list)Any food allergies?YesNo(If yes, list) Do you have a latex allergy?YesNoFamily Medical History: Please check all applicable conditions diagnosed in your biological parents, grandparents, or siblings.Heart DiseaseDiabetesHigh Blood PressureObesitySleep ApneaHyperlipidemiaCancerCerebrovascular Accident (CVA)Peripheral Arterial Disease (PAD)Others basic products/nicotine? of Social, Behavioral & Physical Performance History: Do you have any physical limitations that make exercise difficult?YesNoIf yes, explain:Do you have difficulty with basic mobility or self-care?YesNoDo you use assistive devices for mobility?YesNoHistory of falls in the last 12 months?YesNoCan you walk 1 mile?YesNoCan you go up 2 flights of stairs?YesNoDo you use tobacco products/nicotine?YesNoDo you drink alcohol?YesNoIf yes, how often?RareOccasionalSocialFrequentHeavyDo you use recreational drugs/medications/other substances?YesNoSleep History: How many hours do you sleep per night?4-6 hours6-8 hours8-10 hoursDo you sleep primarily during the:DayNightBothDo you take a sleeping aid?YesNoQuality of SleepPoorGoodVery GoodInterruptedDiet History: Do you have emotional, stress, mental, or boredom eating issues?YesNoIf yes, please specify:Do you binge on food?YesNoDo you crave sweets?YesNoDo you graze throughout the day?YesNoDo you nibble all day long?YesNoWhat kind of dieting have you tried in the past? Mark all applicable supervised and unsupervised diet attempts.Intermittent FastingKeto DietCarbohydrate Restricted DietMedically Supervised DietCaloric Restricted DietPortion Control DietOtherWeight Loss Medication History Have you ever tried weight loss medication in the past?XenicalPhenterminePhendimetrazineContraveSaxenda (Liraglutide)Wegovy (Semaglutide)Zepbound (Tirzepatide)OtherAdditional CommentsSubmit
