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MSB Weight Loss Consent Form

MSB INTAKE FORM

First Name

Last Name

D.O.B.

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a current primary physician? If yes, please list their name below:

Yes

Primary Care Physician:

Do you have allergies to any medicine? If yes, please list them below:

Yes

Please list out all allergies:

Are you currently taking any medications?

Yes

Please list current medications:

Do you have any chronic diseases? (ex. heart/kidney/liver/thyroid/cancer etc)

Yes

Please explain the history of any diseases you have

Do you have a personal history of Pancreatitis?

Yes

Do you have a family history of thyroid cancer?

Yes

Do you have a family history of Multiple Endocrine Neoplasia?

Yes

Have you ever taken weight loss medication?

Yes

If 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

Are you actively attempting to become pregnant?

Yes

Are you attempting to become pregnant within the next 3 months?

Yes

Aging is a disease. The symptoms plague us all, yet the efforts to reverse them are minimal to none. Instead, we have been told to accept these symptoms of aging “gracefully.” Optimizing your health to allow for not only a long, but enjoyable life, is my passion.

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Birmingham, MI 48009

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MSB Weight Loss Consent Form

Aging is a disease. The symptoms plague us all, yet the efforts to reverse them are minimal to none. Instead, we have been told to accept these symptoms of aging “gracefully.” Optimizing your health to allow for not only a long, but enjoyable life, is my passion.

Join our newsletter to receive updates on the latest trends and promotions.

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