NEW PATIENT HEALTH INTAKE FORM NEW PATIENT HEALTH INTAKE FORM There is no obligation for filling out and submitting this form 1Patient Information2PATIENT MEDICAL INFORMATION 3Medical Condition/Medications Date(Required) MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY AgeGender(Required) Male Female Other Other Gender HeightHeight-ftPlease enter a number from 00 to 99.Height-InchPlease enter a number from 00 to 12.WeightCurrent Weight My Pronouns(Required) They/Them/Theirs She/Her/Hers He/Him/His How did you hear about us? Google Search Instagram Radio From Existing TransformRX Client Friend/Family IV Solution website Other How did you hear about us? Other What services are you interested in Medical Weight Loss Nutritional Counseling Body Composition Analysis IV Infusion Therapy Peptide Therapy Lifespan Support Testosterone Therapy NAD+, IV Niagen +, NR Supplement Support Ketamine/SGB for mental health Are you concerned with any of the following? Poor Sleep Lack of energy Lack of focus Anxiety Depression PTSD Chronic Pain Migraines Other Concerned Desired WeightDesired Weight What has been your lowest weight as an adult? Do you have any health conditions that you think are related to your current weight? From what age did you begin having weight problems? In what time frame would you like to be at your desired weight? What is the reason for your decision to lose weight: What weight loss programs or diets have you tried in the past? What method was the most helpful for you? Have you used prescription medicine for weight loss? Yes No If yes: Are you undergoing any lifestyle changes right now?If so, what? Yes No If so, what? Do you binge eat? Yes No Do you suffer from uncontrollable cravings? Yes No Do you feel that food controls you? Yes No Do you eat because of your emotions? Yes No Do you choose to eat between meals often? Yes No (if yes, then explain Do you feel that your eating behaviors are normal? Yes No Briefly describe your daily eating behaviors: Does your family support your weight loss efforts? Yes No Can you remember being at your ideal weight? Yes No Commitment to weight loss: 1 2 3 4 5 6 7 8 9 10 Please select the dietary macronutrients and other things below that you feel have contributed most to your current weight. Carbohydrates Fat Sugar (candy, chocolate, donuts, cake, desserts) Soda and sugary drinks Processed foods Fast food Alcohol Do you exercise regularly? Yes No Days per week? 1-3 days Over 3 days Duration of exercise sessions? 0-30min 31-60min Over 60min Exercise activity Running Cycling Walking Swimming Weights/Resistance Crossfit HIIT Pilates Yoga Other Other(Required) Are you trying for pregnancy or planning pregnancy in the near future? Yes No Are you or could you be pregnant? Yes No Are you breastfeeding? Yes No Are you on any type of hormone replacement therapy? Yes No Alcohol use? Yes No Amount Daily Weekly Socially Tobacco use? Yes Never Former Smoker Packs Per Day How many years? Addiction or Substance use disorder? Yes No Explain What are your goals as you age? To maintain my current level of health To improve my current level of health To lose weight To exercise more To gain muscle weight To improve cellular and DNA quality and function To keep my brain healthy in old age To keep my heart and lungs healthy To avoid or improve risks of age related cognitive decline To reduce the risk of cancer To avoid lower energy levels To improve your mental health To sleep better To improve hydration To keep skin, hair, nails youthful looking Get more active as you age List ALL prescription medications you takeMedication NameDoseFor what conditionsFor how long Add RemoveList ALL supplements you takeSupplementDaily DoseFor what conditionsFor how long Add Remove Do you have any of the following? AIDS/HIV Anemia Arthritis Asthma/Bronchitis Blood Clots Cancer: Cataracts/Glaucoma Complicated Pregnancy Disease Coronary Heart Disease/Angina Diabetes Epilepsy: Emphysema/COPD Endometriosis Gallbladder Disease Gout: Heart Attack Heart Surgery Hepatitis Hernia High Blood Pressure Heart Surgery Hepatitis Hernia High Blood Pressure Heart Surgery Incontinence (urinary/fecal) Joint Replacement Kidney Disease Knee/Ankle Foot Surgery Miscarriage Multiple Sclerosis Neck/ Back Surgery Pins/Metal Implants Parkinsonism Pneumonia Prostate Problems Osteoporosis Pancreatic/Liver Disease Pelvic Inflammatory Disease Vaginal Infection Ulcers Family History of Medullary Thyroid Cancer Personal or family history of Medullary Thyroid Carcinoma (MTC) Personal or family history of Multiple Endocrine Neoplasia Syndrome type 2 (MEN2) Cancer Do you have a diagnosis of any of the following conditions? Depression Anxiety Bipolar Disorder PTSD or Trauma OCD Concussions Traumatic Brain Injury Dementia Alzheimer's Migraines Chronic Pain Neuropathy Do you have any Allergies? Yes No List allergies, pleasePrimary Care Physician Name Primary Care Physician Address Primary Care Physician Phone Number Psychiatrist or Mental Health Professional Name Psychiatrist or Mental Health Professional Address Psychiatrist or Mental Health Professional Phone Number Emergency Contact Name Emergency Contact Relationship Emergency Contact Address Emergency Contact Phone Number Please provide any information about your health, goals, or other services that interest you here:NameThis field is for validation purposes and should be left unchanged.
