Weight Loss RegistrationPersonal DataFirst Name *Middle NameLast Name *Email Address *Home PhoneWork/Cell PhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDate of Birth *EmployerSpouse/PartnerPrimary Care DoctorAgeCurrent WeightHeightSexMedical HistoryDo you now have or have you ever been treated for any of the following?High Blood PressureDepressionHeart DiseaseLung Disease (eg: Asthma)DiabetesHigh cholesterolKidney StonesSleep DisorderGlaucomaThyroid DisorderHormones or Birth controlPlease List ALL Current Medications (include frequency):Please list any major surgeries you have had.Please list any other serious illnesses you have had.Have you ever had or been treated for alcohol or other substance abuse/dependence? Please describe.What would you like to weigh (goal weight)?At what age were you last at that weight?Any previous prescription weight loss medication?Do you smokeMenses regular?Number of childrenPregnant/trying?Any family history of:Heart DiseaseStrokeDiabetesCancerHigh CholesterolObesityDo you exercise regularly? How often? Any problem with exercise?Do you eat nutritiously? Excessively? Do you count calories?Have you been overweight all your life? If not, how long?Any allergies to medicines, including sulfur? If yes, please list:Do you take aspirin, ibuprofen, or naproxen?Please list your preferred pharmacy and location:Various researchers have estimated that one-fourth (1/4) of the United States population is hypothyroid, possibly as high as 40% may be hypothyroid. Please check if you have any of the following physical and/or emotional signs of hypothyroidism.WeaknessDry, coarse skinTiredSwelling of face and eyelidsColdness and cold skinDiminished sweatingCoarse hairPale skinConstipationGain in weightLoss of hairLabored, difficult breathingSwollen feetHoarsenessLoss of appetiteNervousnessHeart palpitationSlow movementPoor memoryEmotional instabilityDepressionHeadachesSend Form
