Weight Loss Qualifier

DATE OF APPLICATION

First Name

Last Name

HOW DID YOU HEAR ABOUT US:

NAME AS IT APPEARS ON YOUR GOVERNMENT ID:

DATE OF BIRTH:

ADDRESS (THIS IS FOR THE PHARMACY TO SHIP THE MEDICATION TO):

Street Address

Address Line 2

City

State / Province / Region

OCCUPATION:

PHONE NUMBER:

EMAIL ADDRESS:

REVIEW OF CURRENT MEDICATIONS:

MEDICATION ALLERGIES:

HEIGHT: (in Inches)

WEIGHT: (in pounds)

TARGET WEIGHT GOAL: (in pounds)

PREVIOUS PRESCRIPTION WEIGHT LOSS MEDICATION:

HOW MUCH WEIGHT HAVE YOU GAINED IN THE PAST 2 YEARS?: (in pounds)

DID YOU EXPERIENCE WEIGHT ISSUES AS A CHILD?

HAVE YOU EVER BEEN DIAGNOSED WITH PCOS (POLYCYSTIC OVARY SYNDROME)?

HAVE YOU EVER BEEN DIAGNOSED WITH DIABETES?

HAVE YOU EVER BEEN DIAGNOSED WITH HTN (HYPERTENSION)?

HAVE YOU EVER BEEN DIAGNOSED WITH HYPERCHOLESTEROLEMIA (HIGH CHOLESTEROL)?

HAVE YOU EVER BEEN DIAGNOSED WITH CHILDHOOD OBESITY?

IS THERE A FAMILY HISTORY OF OBESITY?

IS THERE A FAMILY HISTORY OF HEART DISEASE?

IS THERE A FAMILY HISTORY OF DIABETES?

IS THERE A FAMILY HISTORY OF PCOS FOR FEMALES ONLY? (POLYCYSTIC OVARY SYNDROME)

HAVE YOU EVER HAD A GASTRIC BYPASS?

HAVE YOU EVER HAD A GASTRIC BAND?

HAVE YOU HAD ANY OTHER NON-ORTHOPEDIC SURGERIES? LIST BELOW:

DO YOU HAVE A HISTORY OF THYROID CANCER?

DO YOU HAVE A HISTORY OF MULTIPLE NEOPLASIA 1 OR 2? (CYSTS ON ENDOCRINE GLANDS)

DO YOU HAVE A HISTORY OF PANCREATITIS?

ARE YOU CURRENTLY PREGNANT OR PLAN ON BEING PREGNANT?

WHAT IS YOUR EXERCISE LEVEL? SEDENTARY, MODERATE, OR ACTIVE? PLEASE EXPLAIN.

Please upload Front of Drivers license

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