Very important: after submitting your form, wait for the message indicating it was submitted correctly. Patient intake form (Guided) (1) "*" indicates required fields Step 1 of 7 - Your Goal 14% CompanyThis field is for validation purposes and should be left unchanged.Welcome 👋 Let’s find the right care for you.What brings you in today?* 🔥 Weight Loss 💪 Testosterone / TRT ⚡ Energy & Vitality ❤️ Sexual Health 🧬 Peptides & Anti-aging We’ve got you 💙 Let’s grab a few quick details so our team can reach you.Email* Cell Phone (Must be a cell phone to receive messages)*Please provide a cell phone message so we can SMS text you important notifications. Date MM slash DD slash YYYY Please select an item from the following list:Mr.Ms.Mrs.First nameMiddle name or InitialLast nameGenderMaleFemaleDate of birth MM slash DD slash YYYY Other PhonePlease do not use this for your cell phone. Enter your cell phone in the Cell Phone field to recieve important SMS notifications. Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency contact name First Last Emergency contact relationshipEmergency contact phone Let’s quickly review your health — select anything that applies.Do you have any of these conditions? Alcohol Abuse Anemia Arthritis Asthma Bleeding Disorder Bloody Stool Bronchitis Cancer Chest Pain Constipation Convulsions Depression Diabetes Diarrhea Dizzy Spells Drug Abuse Eating Disorder Epilepsy Fainting Spells Fatigue Food Allergies Frequent Urination Gallbladder Disorder Glaucoma Gout Headaches Heart Disease High Cholesterol Hypertension Insomnia Irregular Pulse Kidney Disease Liver Disease Lung Disease Mental Illness Migraines Moodiness Nervousness Obesity Palpitations Rashes Shortness of Breath Sleep Apnea Stroke Thyroid Disease Type to search, then click each condition that applies.Are you under a doctor's care at the present time?NoYesIf yes, for what? A little medical background helps your provider care for you safely.Reason/DiagnosisYearHospitalAllergiesMedication namePurposeReactionMedication nameDoseFrequency Your daily habits help us personalize your plan.Behavior Style: Please select which one best describes youAlways calm and easygoingUsually calm and easygoingSometimes calm with frequent impatienceSeldom calm and persistently driving for advancementNever calm and have overwhelming ambitionHard-driven and can never relaxWhich best describes your exercise habits?InactiveLight activityModerate activityHeavy activityVigorous activityAre you dieting now?NoYesThird ChoiceIf yes, what diet program?How many meals do you eat in an average day?Rank your fat intake:LowMediumHighRank your salt intake:LowMediumHighRank your caffeine intake:LowMediumHighWhat types of caffeine do you drink? Coffee Tea Soda None How many cups/cans per day?Do you drink alcohol?NoYesDo you use cocktail mixers?NoYesIf yes, what kind?Cigarettes - packs/day?1-23-45+NoneOther Tobacco Products?NoYesHow many years?Women Only - Are you pregnant, trying for pregnancy, or breast feeding?NoYes Tell us a bit about your story, in your own words.What is the main reason you decided to lose weight?When did you begin gaining excess weight? Provide reasons if knownWhat do you think is the main cause of your weight problems?Describe other weight loss programs or previous diets you have followed or attemptedIs your spouse, fiancé/fiancée, or partner overweight? If so, by how many poundsList any food allergies or foods that you avoidWhat foods do you crave more than most others? These are your Passion Foods.What are your snack habits?Do you tend to eat more when you are under a stressful situation?NoYesDo you think you are currently experiencing a stressful situation or emotional upset in your life? Explain.What do you feel are your obstacle(s) to successful weight loss? Almost done! Please review and agree to the items below.Consent for GLP or HCG* I have read and agree to the Consent for GLP or HCG Patient authorization agreement* I have read and agree to the Patient authorization agreement Patient Authorization Agreement* I have read and agree to the Patient Authorization Agreement Financial Policy* I have read and agree to the Financial Policy Signature — type your full name to sign*By typing your name here, you agree this serves as your electronic signature.Drivers License or Other Photo IDMax. file size: 32 MB. Please upload a photo ID with your name and photo on it. Examples include: Drivers License, passport, student ID, Work ID, etc. Must have your name and photo.
