Form Medical Weight Loss Intake Patient Information First Name Middle Name Last Name Birthdate Sex Email Address City State Zip Cell Phone Home Phone Occupation How did you hear about us? Emergency Contact Name Relationship Phone Are you under the care of a qualified healthcare professional? YesNo Please list whom: Primary Physician Physician's Phone As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues- that’s what we’re covering). If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change. Medical History All fields required, type "none" if you have nothing to list Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc…): Please list any allergies you have: What medications, supplements and over the counter items do you take regularly or are currently prescribed: Any past surgeries and hospitalizations? Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer: What is your current weight? What is your current height? Have you ever been on Semaglutide or another medication for Medical Weight Loss? YesNo How Long were you taking the medication? What were the results of the treatment? When did you stop taking the medication? What what the dose and strength you were on? Personal History Do you exercise regularly? Please detail. What kind of other movement or activities do you enjoy? How is your energy? Does your energy level affect your daily activities? Diet and Lifestyle Do you drink/smoke/or use recreational drugs? Food allergies? Food dislikes? Food cravings? How much coffee or tea do you drink daily? How much soda / soft drinks do you drink daily? Do you use sugar substitutes? Please list: What are your worst food habits? How much fluids do you normally drink? Please approximate in ounces. Please list any foods you avoid and the reason (intolerance, allergies). Past food/dieting struggles and difficulties? Past diets, programs, protocols, plans you have tried? What has have worked for you? And what hasn't worked for you? How MOTIVATED are you to lose weight Please list the factors you feel have contributed to your current weight (check all that apply) Slow metabolismFamily history of obesityComfort food dependencyLack of exerciseBinge eatingLate night snackingHistory of traumaHistory of grief and lossMedication related weight gainSignificant restrictive eating behaviors like anorexia HIPAA AUTHORIZATION I acknowledge that I have received a copy of Radiant Recharge LLC's HIPAA Privacy Notice. I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Radiant Recharge to use and disclose my protected health information to carry out: Medical weight management Health coaching I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. I acknowledge the statement above. Sign: You may need to click the submit button twice.
