Weight Loss Registration Form -

Full Name

First

Last

Date of Birth

Email Address

Phone Number

Make sure this a mobile phone to receive text messages

Address

Address Line 1

Address Line 2

City

State

Zip Code

What weight loss medicine are you interested in?

Your Goals (click all the apply)

What have you tried previously for weight loss?

Current Symptoms (past 30 days)

Do You Have a Personal or Family History of Medullary Thyroid Cancer?

Do You Have a Personal or Family History of Multiple Endocrine Neoplasia Type 2 (MEN2)?

Have You Ever Had Pancreatitis?

Female only: Menstrual and Hormonal Status (click all that apply)

Female only: First day of last menstrual period? If applicable

Female only: Have you been diagnosed with any of the following?

PCOS
Fibroids
Endometriosis

Are You Currently Pregnant or Planning to Become Pregnant?

Are You Currently Breastfeeding?

Please list any food or medicine allergies

Current medications and supplements

Please enter one medication/supplement per line.

Are You Currently Taking Any of the Following?

Medical history (conditions, surgeries, allergies)

Check box if any of your family members have any current or previous medical problems.

List any other family medical problems not listed above.

Review of Symptoms: General

cold hands and feet
fever
fatigue
daytime sleepiness

Review of Symptoms: Head, Ears, Eyes:

ROS: Musculoskeletal

ROS: Mood/Nerves

ROS: Cardiovascular

ROS: Urinary

ROS: Digestion

ROS: Respiratory

ROS; Skin

Average sleep hours per night

Do you have problem staying asleep or getting to sleep?

Exercise days per week

Type of exercises

e.g. weights, walking

Do you follow any special diets?

How many meals do you eat a day?

How many meals do you eat out per week?

Stress level (1-10)

Current weight (lbs)

Height (feet, inches)

Average weight as a teenager?

What is your Goal Weight?

Alcohol drinks per week

Tobacco use or Vaping History

Have you taken any recreational drugs in the past?

Any Recent Lab Work?

Yes – I can share with you
Yes – do not have to hand
No – would like labs ordered

Emergency Contact Name

Emergency Contact Phone Number

Primary Care Doctor Name

Our office provides natural medicine and weight loss services to our patients. We do not offer primary care services. We require all patients to establish themselves with a primary care physician and provide our office with this information. We can send out referrals related to your care at our office. We may ask that your primary care doctor request referrals if needed. Our staff does not have hospital privileges and we are unable to treat patients at any hospital. We do not have a practitioner on call for emergencies. If you develop or experience an emergency medical situation, you are advised to contact 911.

PCP phone number

problem week a

Thank you for selecting Dr. Sheila Thomas for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. NO CHECKS. I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection FEES, attorney’s FEES and court FEES. I have read and understand all of the above and have agreed to these statements.

All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

Consent and Acknowledgment

I confirm I am not currently pregnant or planning pregnancy without disclosing this to Dr. Thomas.
I confirm that the information above is accurate to the best of my knowledge.
I understand an initial consultation and lab work are required before any medication can be prescribed
I understand GLP-1 medications are prescription-only and require ongoing medical supervision,
I understand this form does not guarantee enrollment in the program

Please read carefully:Weight loss medicine and related medications require ongoing medical supervision with regular bloodwork, and EKG testing (cardiovascular safety monitoring). Dr. Thomas will only prescribe what is appropriate for your individual case after an initial consultation and baseline labs.

Signature (type your full legal name)

Date