HomePatient formsNew Patient form for weight lossNew Patient Form for Weight Loss NEW PATIENT FORM FOR WEIGHT LOSS SERVICES123456 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 FemaleAddress*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 EmailHow did you hear about us?*Medical HistoryAre you receiving care from other health care professionals? Yes NoIf 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 NoAnemia Yes NoArthritis Yes NoAuto Immune Disorder Yes NoAsthma Yes NoBleeding Disorder Yes NoBlood Disease Yes NoBlood Transfusion Yes NoCancer (Chemo/Radiation) Yes NoDiabetes Yes NoDizziness Yes NoEpilepsy/Seizures Yes NoEczema Yes NoFainting Yes NoHay Fever Yes NoHeart Disease Yes NoHepatitis Yes NoHigh Blood Pressure Yes NoInfection (active) Yes NoKeloid/Hypertrophic Scars Yes NoKidney Disease Yes NoLiver Disease Yes NoMelanoma Yes NoMental Disorder Yes NoNeuromuscular Disorder Yes NoPhotosensitive Conditions Yes NoPigmentation Disorder Yes NoPorphyria Yes NoPsoriasis Yes NoRespiratory Issues Yes NoSkin Disease Yes NoSkin Cancer Yes NoSinus Problems Yes NoStomach Problems Yes NoStroke Yes NoThyroid Disease Yes NoOther Yes NoWhen did you begin to gain weight?After an employment change Yes NoDuring a stressful period Yes NoAfter childbirth Yes NoAfter marriage Yes NoOther Yes NoHow long have you been overweight? year or less 2-5 years 6-10 years 10 yearsWhat is your cause of your weight problem?Frequently overeat Yes NoEnjoy fatting foods Yes NoLack of activity Yes NoHeredity Yes NoOther Yes NoHow 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 monthsWhat other reduction methods have you tried?Weight watchers Yes NoDiet Books Yes NoPhysician Yes NoDo it yourself Yes NoOther Yes NoWhat is the nature of your difficulties while dieting?Are you under a physician’s care? Yes NoHave you been advised by your physician to lose weight? Yes NoDo you have any physical problems that you know are associated with your weight? Yes NoWhy do you want to lose weight?Appearance Yes NoSpecial Occasion Yes NoHealth reasons Yes NoTo please family/friends Yes NoOther Yes NoHas your significant other encouraged you to lose weight? Yes NoHow important is it for you to lose weight? Extremely important Very Important Important Not Very ImportantDo you work? Yes NoNumber of children:Ages:Are any of your children overweight? Yes NoWhat 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 NoWhat 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.