AWE - New Client Intake Form - Arizona Weight Loss & Esthetics

Customer Service

Phone: +1 (480) 603-6895

Client Information

First Name

Last name

Home Phone Number

Cell Phone Number

Email Address

Date of Birth

Address

Age

Gender

Male

Female

Other

Prefer not to say.

How did you hear about us?

Primary Care Doctor

Google

Facebook

Apple Maps

Other

If other please describe.

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe.

Date of your last physical exam

Is there a chance that you are pregnant?

Yes No

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Have you ever been told you have an electrolyte imbalance or abnromal labs? Check all that aply.

Hypermagnesemia (High Magnesium Levels)

Hypercalsemia (HIgh Calcium Levels)

Hypocalemia (Low Potassium Levels)

Hemochromatosis (High Iron Levels)

Other

If other please describe.

Are you a diabetic?

Yes

I think I might be.

Are you a smoker or vaper?

Yes

If Yes, how much do you smoke or vape.

How many alcoholic drinks to you consume in a week?

None. Dont drink.

1-3

3-5

5-10

10-15

15+

Do you use recreational drugs?

Yes

If yes please describe which drugs you use and how often.

Medications (Prescription and Over The Counter)

Please list everything you are taking:

Prescription Medications

Include Strength, Frequency and Condition Being Treated

Over The Counter Drugs

Include Strength, Frequency and Condition Being Treated

Vitamins & Supplements

Include Strength, Frequency and Condition Being Treated

Medical History (Continued)

Do you take digoxin (Lanoxin) for a heart problem?

Yes

Do you take any diuretic or water pills

Yes

If yes please list:

Do you take any steroids, i.e. Prednisone?

Yes

If yes please list:

Do you have any food or medication allergies?

Yes

If yes please list:

List any other medical conditions not listed above.

List all surgical procedures you have had with approximate dates.

is there anything else you would like to tell the physician? If so please explain.

Emergency Contact Information

Add another emergency contact

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