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About Us
Telehealth
Consultation Form
Measurement Chart
Services
Weight Loss
Wellness Medicine
Happiness Medicine
Longevity Medicine
Contact
Consultation Form
1
Step 1
First Name
Last Name
Date
of appointment
date_range
Address
City
State
Zip Code
Phone Number
Email
a valid email
email
Emergency Contact Name
Emergency Contact Phone Number
What Is Your Gender?
Male
Female
Non-binary
Other
Are You 18 Years or Older?
Yes
No
Medical History
Do you have a history of any of the following medical conditions?
Adrenal disorder
Autoimmune disorder
Cardiovascular condition
Cancer/history of cancer
Chemotherapy/radiation
Diabetes
Anemia/blood disorder
Electrolyte imbalances
Depression/anxiety
Ineffective endocarditis
HIV/AIDS or Hepatitis
Pancreatitis
Liver condition/disease
Heart condition/disease
Gastroparesis
Easting disorders
Kidney disease
Thyroid condition
Low potassium
High blood pressure
Hypoglycemia
Thrombosis/phlebitis
Deep vein thrombosis
Other
If "other", please explain
Any chronic medical conditions?
yes
no
If "yes", please detail
Any known allergies?
yes
no
If "yes", please detail
Have you or a family member been diagnosed with either of the following?
Multiple Endocrine Neoplasia Syndrome Type 2
Medullary Thyroid Carcinoma
List any medications you take regularly including vitamins, herbal supplements, aspirin:
Have you had surgery in the past 12 months?
yes
no
If "yes", please detail
Are you allergic to any of the following?
Receptor Agonists
Sodium Phosphate
Adhesives/latex
Are you currently taking blood thinners (ie., Aspirin/Warfarin), Bexarotene, Gotifloxacin, or any Diabetes medication (ie. Insulin or sulfonylureos)?
yes
no
If "yes", please detail
Female Medical History
Are you currently trying/are pregnant, currently nursing or breastfeeding?
yes
no
Have you had a hysterectomy?
yes
no
If ‘Yes’, please detail and describe the outcome:
Number of pregnancies
Live births
Date of last menstrual cycle:
date_range
What is your primary goal?
Weight loss
Improve blood sugar control
Other
Have you previously tried other medications or treatments for weight loss or diabetes management?
yes
no
If 'Yes', please detail and list date:
Do you follow a current diet plan?
yes
no
If "yes", please detail
Do you exercise regularly?
yes
no
If ‘Yes’, how often:
Do you drink alcohol?
yes
no
If ‘Yes’, how often:
Do you drink water daily?
yes
no
If ‘Yes’, how often:
Signature
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