HomePatient formsNew Patient form for weight loss New Patient Form for Weight Loss NEW PATIENT FORM FOR WEIGHT LOSS SERVICES 123456 Patient Information Sheet for weight lossPatient Name:* Today’s date:* MM slash DD slash YYYY Date of Birth:* MM slash DD slash YYYY Age:* Sex:* Male Female Address* City:* City State:* State Zip:* ZIP Cell Phone #:*Occupation:* Email Address:* Emergency contact name:* Relationship:* Phone #:*How do you prefer to receive appointment confirmations?* Phone Call Text Message Email How did you hear about us?* Medical HistoryAre you receiving care from other health care professionals? Yes No If yes, please name them and their specialty: Please list any drugs or medications you are taking: Please list any vitamins/herbs/homeopathies/other you are taking: Allergies:Medication Allergies: Cosmetic Allergies: Latex/Other Allergies: Do you or have you ever had any of the following conditions? Check all that apply:AIDS/HIV Yes No Anemia Yes No Arthritis Yes No Auto Immune Disorder Yes No Asthma Yes No Bleeding Disorder Yes No Blood Disease Yes No Blood Transfusion Yes No Cancer (Chemo/Radiation) Yes No Diabetes Yes No Dizziness Yes No Epilepsy/Seizures Yes No Eczema Yes No Fainting Yes No Hay Fever Yes No Heart Disease Yes No Hepatitis Yes No High Blood Pressure Yes No Infection (active) Yes No Keloid/Hypertrophic Scars Yes No Kidney Disease Yes No Liver Disease Yes No Melanoma Yes No Mental Disorder Yes No Neuromuscular Disorder Yes No Photosensitive Conditions Yes No Pigmentation Disorder Yes No Porphyria Yes No Psoriasis Yes No Respiratory Issues Yes No Skin Disease Yes No Skin Cancer Yes No Sinus Problems Yes No Stomach Problems Yes No Stroke Yes No Thyroid Disease Yes No Other Yes No When did you begin to gain weight?After an employment change Yes No During a stressful period Yes No After childbirth Yes No After marriage Yes No Other Yes No How long have you been overweight? year or less 2-5 years 6-10 years 10 years What is your cause of your weight problem?Frequently overeat Yes No Enjoy fatting foods Yes No Lack of activity Yes No Heredity Yes No Other Yes No How many meals you eat daily? How many serious attempts have you made at dieting? What is the longest you could stick to a diet? 0-1 month 2-6 months 7-12 months over 12 months What other reduction methods have you tried?Weight watchers Yes No Diet Books Yes No Physician Yes No Do it yourself Yes No Other Yes No What is the nature of your difficulties while dieting? Are you under a physician’s care? Yes No Have you been advised by your physician to lose weight? Yes No Do you have any physical problems that you know are associated with your weight? Yes No Why do you want to lose weight?Appearance Yes No Special Occasion Yes No Health reasons Yes No To please family/friends Yes No Other Yes No Has your significant other encouraged you to lose weight? Yes No How important is it for you to lose weight? Extremely important Very Important Important Not Very Important Do you work? Yes No Number of children: Ages: Are any of your children overweight? Yes No What is your current weight? What was your highest weight in the last 5 years? What was your lowest weight in the last 5 years? Do you have sulfa allergy? Yes No What is your goal weight?I wish to apply for admission to the Allure Aesthetic Center Weight Loss Program. I realize that admission cannot be guaranteed, and will depend on results of a comprehensive medical evaluation I am aware of the financial and time commitments involved, and feel I can complete the program.* The above information is accurate to the best of my knowledge.
