Step 1 of 4 25% Medical Weight Loss Program Intake FormName(Required) First MI Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email Birth Date(Required) MM slash DD slash YYYY AgeSex(Required)Please SelectMaleFemaleOccupation In Case of EmergencyFull Name(Required) Relationship(Required) Phone(Required)How did you hear about us? Are you under the care of a qualified healthcare professional? Please list whom.(Required)Medical History<,/b>Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc…):(Required)What medications, supplements and over the counter items do you take regularly or are currently prescribed:(Required)Please list any past surgeries and hospitalizations?(Required)Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer: Diet and LifestyleDo you regularly drink alcoholic beverages?(Required)Please SelectYesNoHow many per week? Do you smoke tobacco?(Required)Please SelectYesNoDo you use recreational drugs?(Required)Please SelectYesNoHow often do you exercise: How is your appetite? What nutritional diet do you normally follow: Is there anything else you would like to tell us?Please list the factors you feel have contributed to your current weight (check all that apply):Untitled Slow metabolism Family history of obesity Comfort food dependency Lack of exercise Binge eating Select AllUntitled Late night snacking History of trauma History of grief and loss Medication related weight gain Significant restrictive eating behaviors like anorexia Select All Please answer the following questions to the best of your knowledge: Health HIstoryFatigue(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Unexplained weight loss or gain(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Change in appetite(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Depressive symptoms(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Anxiety(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Mood swings(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Nervousness(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Addictive dependency(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Disordered Eating Pattern/Tendency(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Tension(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Lack of mental focus(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Thyroid problems(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Diabetes(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Blood sugar irregularities(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Excessive thirst or hunger(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Sugar cravings(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Abnormal hair growth(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Excessive perspiration(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Feeling excessively hot or cold(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Headache(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Lightheadednes(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Joint pain or stiffness(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Muscle weakness or soreness(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago High blood pressure(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Heart murmur/palpitations(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Cold or pale extremities(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Asthma(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Short of breath(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Heartburn(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Abdominal discomfort after eating(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Nausea(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Abdominal bloating(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Belching/gas(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Constipation(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Diarrhea(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago Daily bowel movements(Required) No, never Yes, currently Not currently, but within the last year No, never Yes, currently Not currently, but within the last year Not currently and longer than 1 year ago As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues- that’s what we’re covering). If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change. I acknowledge the above statement above. Signature(Required)Date(Required) MM slash DD slash YYYY Better Health Care is Our Mission 24/7 service. Same Day Appointments are Available. (660)339-6006 660ivhealth@gmail.com Book an Appointment Today!
