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Medical History
Patient’s information
Name
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Name
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First
Middle
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Last
Last
Date of Birth
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Were you referred by someone? If so, who?
What service(s) are you interested in?
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Medical Weight Loss Program
TRT or HGH
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Emergency Contact
Emergency Contact Name
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Emergency Contact Name
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Relationship to Patient
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Medical History
Check the symptoms that you’ re currently experiencing:
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Diabetes
Ear / Nose / Throat
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Are you currently taking any medications?
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Yes
Yes
Do you have any known medical allergies?
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No
Yes
Yes
Are you currently under medical treatment?
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Yes
Yes
Have you been admitted to hospital or had surgery within the last 2 years?
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No
Yes
Do you use any kind of tobacco or have you ever used them?
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No
Yes
Yes
Do you use any kind of illegal drugs or have you ever used them?
*
No
Yes
Yes
Do you use any kind of history of Pancreatic Disease or Pancreatitis?
*
No
Yes
Yes
Do you use any kind of history of Thyroid Disease?
*
No
Yes
Yes
Do you use any kind of history of Multiple Endocrine Neoplasia?
*
No
Yes
Yes
Do you use any kind of history of Type 1 Diabetes?
*
No
Yes
Yes
Do you have any other diseases or conditions? If so, please list them.
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Height
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Current Weight
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Desired Weight
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How often do you consume alcohol?
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Insurance
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