Patient Medical Weight Loss | Houston Medical Wellness Clinic

Medical Weight Loss Patient Infomation

Genetic Gender(Required)

Male

Female

DOB(Required)

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Enter Email Confirm Email

Who referred you?

Name / Google / Facebook / Instagram / Other

Bone Size(Required)

Small

Medium

Large

Body Type(Required)

Androgenic (Narrow hips, fat carried in abdomen)

Estrogenic (Pear shape, larger hips/thighs)

Have you ever participated in a weight loss program before(Required)

Yes

Have you ever taken a weight loss medication(Required)

Yes

If YES which medication

If YES how long were you on the medication for

If YES when was the last time you took the medication

How long has it been since you noticed the difference in your weight

Please mark the participating factors that pertain to you.

Other / Additional Details / Date of Diagnosis

Past Medical History?

PMHx Other

Past Surgical History?

PSHx Other

Family History?

Adopted

Cancer

Depression

Diabetes

Heart Disease

High Blood Pressure

Obesity

Stroke

Other (specify)

FHx Other

Social History?

Drinking

Smoking

Caffeine

Never

SHx Alcohol Details

SHx Tobacco Details

SHx Caffeine Details

Are you currently taking any Medications or Supplements? If Yes, please list with dosage.(Required)

Yes

Medications & Supplements currently taking.

Medications & Supplements currently taking, line 2

Medications & Supplements currently taking, line 3

Medications & Supplements currently taking, line 4

Are you allergic to any medications or supplements?(Required)

Yes

Allergies - Please check all that apply & state reaction

Medication and Reaction

Are you taking any Over The Counter (OTC) medications?(Required)

Yes

Over the Counter (OTC) Information:

Please select all products that you use occasionally or regularly.

OTC Other

Do you follow a certain diet?(Required)

Yes

Diet Specify?

Describe your typical daily food intake:

First Meal(Required)

Second Meal(Required)

Third Meal(Required)

Fourth Meal(Required)

Do you Exercise?(Required)

Yes

Do you Exercise? What type / How often?

Do you Practice Stress Management?(Required)

Yes

Stress Management Techniques

Have you ever used oral contraceptives?(Required)

Yes

Contraceptive Use

BreastFeeding(Required)

Yes

When was your last menstrual cycle

How many days did it last?

Since your first period, have you ever had what you would consider abnormal cycles?(Required)

Yes

Abnormal Cycles Details.

How many pregnancies have you had?(Required)

How many children?

Were you prematurely grey?(Required)

Yes

Have you had any of the following test performed? Date all that apply.

Mammography?(Required)

Yes

Date

PAP Smear(Required)

Yes

Date

Do you have, or have you ever experienced Premenstrual Syndrome (PMS)?(Required)

Yes

Do you have, or have you ever experienced Premenstrual Syndrome (PMS)? If yes, please explain symptoms :

Have you experienced any of the following symptoms recently? Please select the number that best describes your experiences, with ONE being extremely mild and TEN being extremely severe.

Sleep Disruptions(Required)

Fatigue(Required)

Vaginal Dryness(Required)

Iritability(Required)

Nervousness(Required)

Breast Tenderness(Required)

Hot Flashes(Required)

Dry Skin(Required)

Mood Swings(Required)

Arthritis(Required)

Loss of Recent Memory(Required)

Weight Gain(Required)

Decreased Sex Drive(Required)

Depression(Required)

Fluid Retention(Required)

Headaches(Required)

Night Sweats(Required)

Hair Loss(Required)

Harder to Reach Climax(Required)

Bladder Symptoms(Required)

Other (rate & explain)

Other Symptoms Rating

This field is hidden when viewing the form

Sleep Disruptions(Required)

Fatigue(Required)

Irritability(Required)

Nervousness(Required)

Mood Swings(Required)

Arthritis(Required)

Loss of Recent Memory(Required)

Weight Gain(Required)

Decreased Sex Drive(Required)

Depression(Required)

Fluid Retention(Required)

Headaches(Required)

Hair Loss(Required)

Harder to Reach Climax(Required)

Bladder Symptoms(Required)

Other (Rate & Explain)

Other (explain) Male

Additional Notes for Provider

Legal Consent(Required)

I agree to the terms and conditions.

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

My signature below means I understand the following. All of the information I have provided is true and to the best of my knowledge.

Signature(Required)

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