Weight Loss

Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

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No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

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Unfortunately we cannot proceed with your request based on the information you have provided.

What is your Current Weight?*

What is your height?*

Do you have or are you at risk for any of the following conditions?*

Explain Your Weight Loss History*

Include all of the following your history: Current weight, Highest weight in last 10 years, Lowest weight in last 10 years, Typical breakfast, lunch & dinner, Typical daily snacking, Typical in one day drinking (including alcoholic beverage), Exercise frequency and type, & Disordered eating.

How long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for weight loss?*

Yes
No

How long ago?*

What medications were you treated with?*

Please list the treatment plan:*

Did treatment work?*

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No

Would you prefer the same treatment?*

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No
Leave to doctor’s discretion

Smoker?*

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Never

Alcohol use?*

Any medical family history?*

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Please explain your medical family history:*

Do you have any medical conditions?*

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Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

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Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

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Please list any medications, herbals, or supplements:*

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Weight Loss

Weight Loss

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