Language
English (US)
Español
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?
*
Towson
Ellicott City
Abingdon
Frederick
Glen Burnie
Perry Hall
Name
*
Sex
*
Male
Female
N/A
Marital Status
Single
Married
Divorced
Widowed
Other
Current Date
/
Month
/
Day
Year
Date of Birth
*
/
Month
/
Day
Year
Age
Date of Birth-drop down
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
*
Contact Number:
*
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)
-
Month
-
Day
Year
Date
Back
Next
Medical Information
Please check all that apply.
Your Medical Conditions
Hypertension/ High Blood Pressure
Heart Disease
Heart Attack/ Chest Pain
Stroke
High Cholesterol
Heart Murmur/ Heart Palpitations
Peripheral Vascular Disease
Thyroid Disease
Diabetes
Kidney Disease
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
Gallbladder Disease
Multiple Sclerosis
Cancer
Substance Abuse
None
Please describe any other medical conditions you have
Please select any that apply to you:
Currently Pregnant
Planning to become pregnant soon
Breastfeeding
Back
Next
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
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
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
Glaucoma
Arthritis
Mental Health Disorder
Anemia
Rheumatoid Arthritis
GI disorder
Cancer
Substance Abuse
Back
Next
Medical Information Cont.
How much do you weigh? (lbs)
*
How tall are you?
*
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?
*
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.
*
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?
*
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?
*
Yes
No
Drug Allergies
Have you ever had surgery or been hospitalized?
*
Yes
No
Surgery and Hospitalization History
Have you ever been treated for an eating disorder?
*
Yes
No
Back
Next
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
Non-Surgical Body Contouring
Non-Surgical Skin Tightening
Ketogenic Diet
Intermittent Fasting
Hypnosis for Weight Loss
Body Composition Analysis
Back
Next
Photo ID
Please upload a picture of your government issued picture ID (driver license, passport, military ID etc.)
Upload a picture of your photo ID
Browse Files
Cancel
of
Back
Next
Treatment Waiver
Signature
Clear
Telehealth Informed Consent Form
Signature
Clear
Submit
Should be Empty: