Weight Loss Intake

Name:

DOB:

Age:

Gender:

Weight:

Height:

Please list medications taken:

Add medication

Drug use?

Yes No

If yes, what drug?

Dosage:

How many times/day?

Marijuana use?

Yes No

If yes, how many times/day?

Dosage:

Tobacco use?

Yes No

If yes, how many times/day?

Do you follow a diet?

Yes No

Have you ever taken medications for weight loss?

Yes No

Do you exercise?

Yes No

If yes, what kind?

How often?

Do you have high blood pressure or previously treated for or currently treated for any heart related diseases?

Yes No

Do you have high cholesterol?

Yes No