New Patient form for weight loss NEW PATIENT FORM FOR WEIGHT LOSS SERVICES 1 2 3 4 5 6 Patient Information Sheet for weight lossPatient Name:*Today’s date:* Date Format: MM slash DD slash YYYY Date of Birth:* Date Format: MM slash DD slash YYYY Age:*Sex:*MaleFemaleAddress*City:* City State:* State Zip:* ZIP Cell Phone #:*Occupation:*Email Address:* Emergency contact name:*Relationship:*Phone #:*How do you prefer to receive appointment confirmations?*Phone CallText MessageEmailHow did you hear about us?* Medical HistoryAre you receiving care from other health care professionals?YesNoIf yes, please name them and their specialty:Please list any drugs or medications you are taking:Please list any vitamins/herbs/homeopathies/other you are taking:Allergies:Medication Allergies:Cosmetic Allergies:Latex/Other Allergies: Do you or have you ever had any of the following conditions? Check all that apply:AIDS/HIVYesNoAnemiaYesNoArthritisYesNoAuto Immune DisorderYesNoAsthmaYesNoBleeding DisorderYesNoBlood DiseaseYesNoBlood TransfusionYesNoCancer (Chemo/Radiation)YesNoDiabetesYesNoDizzinessYesNoEpilepsy/SeizuresYesNoEczemaYesNoFaintingYesNoHay FeverYesNoHeart DiseaseYesNoHepatitisYesNoHigh Blood PressureYesNoInfection (active)YesNoKeloid/Hypertrophic ScarsYesNoKidney DiseaseYesNoLiver DiseaseYesNoMelanomaYesNoMental DisorderYesNoNeuromuscular DisorderYesNoPhotosensitive ConditionsYesNoPigmentation DisorderYesNoPorphyriaYesNoPsoriasisYesNoRespiratory IssuesYesNoSkin DiseaseYesNoSkin CancerYesNoSinus ProblemsYesNoStomach ProblemsYesNoStrokeYesNoThyroid DiseaseYesNoOtherYesNo When did you begin to gain weight?After an employment changeYesNoDuring a stressful periodYesNoAfter childbirthYesNoAfter marriageYesNoOtherYesNoHow long have you been overweight?year or less2-5 years6-10 years10 yearsWhat is your cause of your weight problem?Frequently overeatYesNoEnjoy fatting foodsYesNoLack of activityYesNoHeredityYesNoOtherYesNoHow many meals you eat daily?How many serious attempts have you made at dieting?What is the longest you could stick to a diet?0-1 month2-6 months7-12 monthsover 12 months What other reduction methods have you tried?Weight watchersYesNoDiet BooksYesNoPhysicianYesNoDo it yourselfYesNoOtherYesNoWhat is the nature of your difficulties while dieting?Are you under a physician’s care?YesNoHave you been advised by your physician to lose weight?YesNoDo you have any physical problems that you know are associated with your weight?YesNo Why do you want to lose weight?AppearanceYesNoSpecial OccasionYesNoHealth reasonsYesNoTo please family/friendsYesNoOtherYesNoHas your significant other encourage you to lose weight?YesNoHow important is it for you to lose weight?Extremely importantVery ImportantImportantNot Very ImportantDo you work?YesNoNumber of children:Ages:Are any of your children overweight?YesNoWhat is your current weight?What was your highest weight in the last 5 years?What was your lowers weight in the last 5 years?What is your goal weight?Do you have sulfa allergy?YesNoWhat is your goal weight?I wish to apply for admission to the Allure Aesthetic Center Weight Loss Program. I realize that admission cannot be guaranteed, and will depend on results of a comprehensive medical evaluation I am aware of the financial and time commitments involved, and feel I can complete the program.* The above information is accurate to the best of my knowledge. This iframe contains the logic required to handle Ajax powered Gravity Forms.