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Weight Loss Consultation Intake Form
Head2Toe Health
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* Indicates required question
Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Address
Your answer
Phone number
*
Your answer
Email
*
Your answer
Past Medical History/Surgeries/Hospitalizations
Your answer
Allergies
*
Your answer
Current Medications/Vitamins/Supplements:
*
Your answer
Are you interested in getting help to lose weight?
*
Yes
No
Have you tried diet and exercise?
*
Yes
No
Have you taken any over-the-counter or prescription diet medications in the past?
*
Yes
No
If yes, please list:
Your answer
Did you experience any complications or side effects?
Your answer
Has a physician ever diagnosed you with any of the following medical conditions:
*
Heart Disease (CAD) or Heart Failure
Overactive thyroid or hyperthyroidism
Heart Arrythmias or syncope
Glaucoma
Blood pressure over 200/100
Anorexia or Bulimia
Stroke, seizure, or epilepsy
Substance abuse
Multiple Endocrine Neoplasia II
Medullary Thyroid Cancer
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