MW WELLNESS

Weight Loss & GLP-1 Therapy Intake

All information is confidential and used for medical evaluation only

First Name

Last Name

Who can we thank for referring you? *

Phone *

Address

Street Address

City

State

Country

Postal Code

Date of birth

Email *

Gender: Female Male

Current Weight Goal Weight Height

Have you ever tried to lose weight before?

If yes, what methods have you tried?

Diet & Exercise

Commercial Programs (Weight Watchers, Jenny Craig, etc.)

Prescription Weight Loss Medication

Over the counter Supplements/Bariatric Surgery, Other

Medical History:

Personal history of Medullary Thyroid Cancer

History of severe gastroparesis or digestive disorder

Pregnant or plan to get pregnant

Breastfeeding

Kidney Disease, Liver Disease, Pancreatitis Cancer

High Blood Pressure

Gallbladder Disease

Diabetes Type 1 or Type 2

High Cholesterol

Current Medications

Patient Acknowledgement

I certify that the information provided above is true and complete to the best of my knowledge. I understand that this information will be used to determine my eligibility for weight loss therapy and that withholding information may affect my treatment.

Date: ______________________

Signature

Clear

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