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Weight Loss Program Intake Form

Asks about current weight, height & BMI, medical conditions screening, and current medications & supplements. Built for medical weight management clinics enrolling patients in structured weight loss programs.

Questions
16
Pages
2
Time
about 4 min

Includes

  • Consent agreement
  • Insurance details
  • Medication list
  • Allergy list
  • Conditions checklist
  • Emergency contact
  • Card payment
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Your practice

Weight Loss Program Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Medical weight management clinics enrolling patients in structured weight loss programs
  • Obesity medicine practices collecting intake data for GLP-1 and pharmacotherapy candidates
  • Bariatric surgery centers screening patients before surgical consultation
  • Primary care offices onboarding patients into insurance-covered weight loss programs

Formisoft for Mental HealthFormisoft for Weight Loss

What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Current Weight, Height & BMIText

Page 2 · Additional details

  1. Diet History & Eating PatternsLong Text
  2. Exercise & Physical Activity LevelLong Text
  3. Prior Weight Loss Programs AttemptedLong Text
  4. Weight Loss Goals & MotivationLong Text
  5. Insurance InformationInsurance Info

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Weight Loss Program Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Weight Loss Program Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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