New Patient Interest Form
Please fill out this brief questionnaire to determine if our program is the best fit for your weight loss and wellness needs.

Don't worry! There is no commitment. We just want to learn more about your weight loss struggles and goals.
Dr. Bell and THWMD Staff will review your responses and contact you in 1-2 business days after completion.

This survey should only take 3-5 minutes.

 Thank you!
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Email *
Please select what state you are in. Dr. Bell can only see patients in Massachusetts, Virginia, Georgia, Florida, and North Carolina - remotely of course!  *
Required
Today's Date *
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Weight Management Screen
What is your name? Please include your pronouns. *
Please provide an email where you can receive confidential messages: *
When is your birthday ? *
Before we begin, how did you hear about The Healthy Weigh MD?  (Google, Word of Mouth, Psychology Today, other...) *
By checking Yes to acknowledge that you understand the following: Completing this form does not imply or establish a physician- patient relationship. All responses are confidential.   I understand that my level of success  and results greatly depend on genetics, psychosocial stressors, and my ability to follow and commit fully to the plan. *
Required
The Healthy Weigh MD, PLLC does not accept insurance and is considered an out of network or cash pay practice. By making this appointment, I affirm that I live in NC, VA,  MA, FL, or GA. I understand that Dr. Bell can only see patients in these 5 states currently.  Because this is a virtual appointment, I understand that Dr. Bell does not prescribe controlled substances.  She will, however, evaluate me and provide  Anti-Obesity (AOMs) Medications if appropriate, which will be determined by my consultation evaluation. I will do my best to honestly provide as much information to aid in an appropriate diagnosis as possible. *
Required
Are you concerned about your weight?
Clear selection
How long has your weight been an issue? *
Required
Have you tried to lose weight before?
Clear selection
How much weight would you like to lose? *
Do you have any (weight related) health issues?
Clear selection
Do you feel emotional issues contributed to your weight gain?
Clear selection
Do you have a history of eating disorders?
Clear selection
Do you have any diagnosed mental health issues?
NO diagnosed mental illness
Depression
Bipolar Disorder
Schizophrenia
Psychosis/Psychotic Disorders
Anxiety
OCD - Obsessive Compulsive Disorder
PPD - Post Partum Depression/Anxiety
I have...
Do you have a high stress job or life?
Clear selection
Do you have any weight-related fertility concerns or plan to get pregnant in the next year?
Clear selection
How confident do you feel that you will succeed at weight-loss this time?  Please rank your confidence from 1 (low) to 10 (high). *
There is no way I can lose weight
I will ABSOLUTELY reach my goals this time.
How ready to start the weight loss program do you feel at this time? Please rank your confidence from 1 (low) to 10 (high).   *
I am not ready to get started yet
I would like to start TODAY! I can't wait to get started.
Do you have a  Primary Care Doctor?   Does your PCP know you are pursuing weight loss treatment?  We coordinate care with your PCP to help monitor your improvement during the program. *
Required
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