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New Patient Form
Please complete and submit this form prior to your appointment. This form has 6 pages that include registration, medical history, lifestyle information, and treatment waiver.
Which office location are you visiting?
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Abingdon
Ellicott City
Frederick
Glen Burnie
Hagerstown
Perry Hall
Rockville
Towson
Name
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Sex
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Male
Female
Marital Status
Single
Married
Divorced
Widowed
Other
Current Date
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Month
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Day
Year
Date of Birth
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Month
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Day
Year
Age
Date of Birth-drop down
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January
February
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Year
Address:
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Street Address
Street Address Line 2
City
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Texas
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State
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E-mail
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Contact Number:
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Phone Number
Occupation:
Emergency Contact:
Name
Phone Number
Relationship to you
Primary Care Doctor:
Name
Phone Number
Date of last primary care visit (check-up or sick visit)
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Month
-
Day
Year
Date
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Medical Information
Do you or any of your family members have Medullary Thyroid Cancer or Multiple Endocrine Neoplasia?
No
Yes
Your Medical Conditions
Multiple Endocrine Neoplasia
Medullary Thyroid Cancer
Gallbladder Disease
Kidney Disease
Panceratitis
Hypertension/ High Blood Pressure
Heart Disease
Heart Attack/ Chest Pain
Stroke
High Cholesterol
Heart Murmur/ Heart Palpitations
Peripheral Vascular Disease
Thyroid Disease
Diabetes
Epilepsy/Convulsions
Glaucoma
Arthritis
Gout
Osteoporosis
Insomnia
Asthma/emphysema
Anxiety
Depression
ADD/ADHD
Other Mental Health Disorder (Bipolar ect.)
Anemia
Bleeding Disorder
Rheumatoid Arthritis
GI disorder
Bowel Irregularity
Multiple Sclerosis
Cancer
Substance Abuse
None
Please describe any other medical conditions you have
Please select any that apply to you: (Any of these disqualify you from treatment)
Trying to become pregnant
Currently Pregnant
Breastfeeding
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Family Medical Information
Please check all that apply to you biological relatives
Family Medical History- FATHER
Overweight
Hypertension/ High Blood Pressure
Heart Disease/ Stroke
Thyroid Disease
Diabetes
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Glaucoma
Arthritis
Mental Health Disorder
Anemia
Rheumatoid Arthritis
GI disorder
Cancer
Substance Abuse
Family Medical History- MOTHER
Overweight
Hypertension/ High Blood Pressure
Heart Disease/ Stroke
Thyroid Disease
Diabetes
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Glaucoma
Arthritis
Mental Health Disorder
Anemia
Rheumatoid Arthritis
GI disorder
Cancer
Substance Abuse
Family Medical History- SIBLING(S)
Overweight
Hypertension/ High Blood Pressure
Heart Disease/ Stroke
Thyroid Disease
Diabetes
Medullary Thyroid Cancer
Multiple Endocrine Neoplasia
Glaucoma
Arthritis
Mental Health Disorder
Anemia
Rheumatoid Arthritis
GI disorder
Cancer
Substance Abuse
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Medical Information Cont.
How much do you weigh? (lbs)
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How tall are you?
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4'
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5'
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6'
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
6' 7"
6' 8"
6' 9"
6' 10"
6' 11"
7'
7' 1"
7' 2"
7' 3"
BMI
What was your latest blood pressure? (Example: 120/80)
EX: 120/80
Are you currently taking any medications?
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Yes
No
Please list all medications you are current taking (including birth control)
Have you ever taken prescription weight loss medication? This does NOT include over the counter products like hydroxycut etc.
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Yes
No
Please list any prescription weight loss medications you have previously taken.
Was the prescription weight loss medication effective?
Very Effective
Somewhat Effective
Not Effective
Did you have any side effects from the prescription weight loss medication?
Yes
No
What side effects did you experience?
Have you ever taken Lipotropic or Vitamin Injections for weight loss?
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Yes
No
Did you have any side effects from Lipotropic or Vitamin Injections?
Yes
No
What side effects did you experience?
Are you allergic to any medications?
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Yes
No
Drug Allergies
Have you ever had surgery or been hospitalized?
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Yes
No
Surgery and Hospitalization History
Have you ever been treated for an eating disorder?
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Yes
No
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Goals and Lifestyle Information
What are your weight loss goals?
EX: Pass military/police force PT test, Ease joint pain/prevent joint replacement, General health, Look good for the wedding, Save money on health care, Have energy for my kids, Weigh X lbs etc.
How many MEALS do you eat a day?
0
1
2
3
4
5
6
7+
How many SNACKS do you eat a day?
0
1
2
3
4
5
Are you currently following a specific diet? (EX: vegetarian)
Yes
No
Describe the diet you are following:
Which of the following drinks do you have once a week or more? (Check all that apply)
Coffee
Alcohol
Regular Soda
Diet Soda
Juice
Smoothies
Sports Drinks
Sweetened Drinks
Protein Shakes (EX: Slim fast ect.)
How many cups of coffee do you drink a DAY?
What do you put in your coffee? (Check all that apply)
Nothing, black
Sugar
Artificial Sweetener (EX: Splenda, Sweet' N Low, Equal, Stevia etc.)
Milk
Unsweetened Creamer (EX: Half & Half or Heavy Cream)
Flavored/Sweetened Creamer
Butter/MTC oil/Coconut Oil
Supplements (EX: Collagen)
How many drinks of alcohol do you have a WEEK?
How many days per week do you eat fast food or dine out?
0
1
2
3
4
5
6
7
Who usually prepares your food?
Myself
A family member
Grocery Store (Prepared Foods)
Restaurants
Do you have any food cravings?
Yes
No
Describe your food cravings. (Types of foods and times of day)
Do you take any of vitamins or supplements? (Check all that apply)
Multivitamin (capsule/table)
Gummy Multivitamin
Powder Multivitamin (EX: EmergenC ect.)
Iron
Fish oil
Vitamin D
Vitamin B12
Collegen
Do you smoke or use tobacco products?
Yes
No
Do you exercise regularly?
Yes
No
Describe your exercise habits (types of exercise and frequency)
How many hours do you usually sleep each night?
Think about the past week and write examples of what you eat for meals and snacks:
What does a "healthy diet" mean to you?
Are you interested in learning more about any of these services? (Check all that apply. Some services are only available in select offices)
Lipotropic/Vitamin Injection
Ketogenic Diet
Intermittent Fasting
Body Composition Analysis
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Treatment Waiver
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Telehealth Informed Consent Form
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