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Please fill out the following form before the visit

First Name

Email Address

Phone Number

Last Name

Date of Birth

Zip Code

Address

Have you unexplained elevated blood pressure within the last 12 months?

No

Yes

Past Medical History: Check all that apply.

NONE

Thyroid disease

Hypertension

Heart condition (heart failure, arrhythmia, hx of heart attack...)

Elevated Cholesterol

Diabeter Mellitus

Liver disease

Kidney disease

Neurological conditions ( stroke, seizures disorder...)

Depression, Anxiety or other psychiatric disorder

Currenlty Pregnant ( WOMEN ONLY)

Currently Breastfeeding ( WOMEN ONLY)

Other medical conditions

I declare that the info I’ve provided is accurate & complete

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Do you have any known medical allergies?

No

Yes

Medications

Surgical History:

Family History

Diet & Exercise History:

Initials

Today's Date

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I accept terms & conditions HIPAAView terms of use

I accept terms & conditions and consent to the weight loss program View consent form

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