Personal Information

Today's Date * +

First Name *

Last Name *

Date of Birth * +

Gender *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone number we may use to reach you *

Would you like to provide an alternate phone number? *

Email Address *

Re-enter email address *

Emergency contact and phone number: *

Employer (enter "None" if not working) *

Occupation (enter "None" if applicable) *

How did you find us? *

Name of the person that referred you:

May we thank them for the referral?

Please explain how you found us:

Medical History

Do you have a primary care physician? *

Primary Care Physician Name and Phone Number:

Do you see any other medical care specialists? *

Please enter the following information about your specialist(s):
NAME - SPECIALTY - CONDITION BEING TREATED

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Please check any conditions or illnesses you have or have had in the past

Do you take any over the counter medications? (ie: vitamins, ibuprofen, natural supplements, etc) *

Please list any over the counter medication you take. *

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Do you take any prescription medication? *

Please list all the over the prescription medications you currently take (prescription and over the counter) and the condition for which you take it. Example: Prilosec - acid reflux * 🛈

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Do you have any allergies to medication or food? *

Please list any allergies you have to any food or medication * 🛈

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Have you had any surgery in the past? *

Surgical history and year. Example: Appendectomy - 1995 🛈

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Have you ever been hospitalized? *

List any hospitalizations and discharge diagnosis. Example: Chest pain - diagnosis anxiety
🛈

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Does anyone in your immediate family have any of the following: Diabetes, Cancer, High Blood Pressure, High Cholesterol, Obesity, Thyroid Disease, or other significant illness? *

Family medical history. Example: Mom - high blood pressure 🛈

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Social History

Please check all that apply: *

Weight Loss History

How long have you been trying to lose weight?

What has been your highest weight?

What is your biggest obstacle in losing/maintaining your weight? *

Have you tried any other diet programs in the past? *

What other diet programs have you tried in the past?

By signing my name below, I am certifying that I have carefully answered each question truthfully and to the best of my ability. *

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Allergies	Asthma	Anorexia	Alcoholism
Arthritis	Anxiety	Atrial Fibrillation	Acid Reflux
Bullimia	Cancer	Constipation	Diabetes
Depression	Dug Addiction	Glaucoma	Hypertension
Heart Disease	High Cholesterol	Thyroid Problem	Insomnia
Kidney Problem	Other Other

Smoking	Alcohol	Married
Divorced	Caffeine use	Frequent travel
Drug use	Eat out frequently	Eat mostly at home
Have children	Do not have children	Other Other

Weight Watchers	Jenny Craig	Medifast
Transformations	Atkins	Nutrisystem
South Beach	HCG injections	Other Other