MSB Weight Loss Consent Form MSB INTAKE FORMΔ First NameLast NameD.O.B.PhoneEmailAddressAddress Line 1Address Line 2CityStateZip CodeDo you have a current primary physician? If yes, please list their name below: Yes NoPrimary Care Physician:Do you have allergies to any medicine? If yes, please list them below: Yes NoPlease list out all allergies:Are you currently taking any medications? Yes NoPlease list current medications:Do you have any chronic diseases? (ex. heart/kidney/liver/thyroid/cancer etc) Yes NoPlease explain the history of any diseases you haveDo you have a personal history of Pancreatitis? Yes NoDo you have a family history of thyroid cancer? Yes NoDo you have a family history of Multiple Endocrine Neoplasia? Yes NoHave you ever taken weight loss medication? Yes NoIf yes, explain when and what below: What is your height?What is your current weight?What is your lowest adult weight?What is your weight goal?Were you referred? If so, by who?Are you pregnant? Yes NoAre you actively attempting to become pregnant? Yes NoAre you attempting to become pregnant within the next 3 months? Yes NoSubmit Form