Weight Loss Program Intake Form

The Weight Loss Program Intake Form is designed for medical weight management clinics, obesity medicine practices, bariatric pre-surgical screening programs, employer wellness initiatives, and primary care offices that offer structured weight loss programs. This weight loss clinic intake form captures the comprehensive clinical and lifestyle data that providers need to develop a safe, personalized treatment plan, whether the patient is pursuing dietary counseling, pharmacotherapy (GLP-1 agonists like semaglutide or tirzepatide, phentermine, orlistat), medically supervised meal replacement programs, or surgical evaluation.

The form begins with patient demographics and a thorough medical history, including cardiovascular conditions, diabetes and insulin resistance, sleep apnea, PCOS, thyroid disorders, joint problems, and mental health conditions that may affect weight or treatment options. The conditions checklist screens for contraindications to weight-loss medications and ensures the provider is aware of comorbidities. Current medications and supplements are documented in detail, as many drugs affect weight (antidepressants, corticosteroids, insulin, beta-blockers) and must be factored into the treatment plan. A dedicated allergies section covers food allergies, drug allergies, and latex sensitivities. The lifestyle assessment captures current weight, height, waist circumference, target weight, diet history (prior programs attempted, dietary patterns, meal frequency, snacking habits, emotional eating triggers), physical activity level, exercise preferences, barriers to exercise, alcohol and tobacco use, and sleep duration and quality.

Patients describe their weight loss goals and motivations in a free-text field, allowing the provider to understand the patient's expectations and align the treatment plan accordingly. The insurance information section supports coverage verification for medically necessary weight management services and GLP-1 prior authorization. An integrated Stripe payment field enables clinics to collect program enrollment fees, consultation deposits, or medication co-pays at the time of intake. The consent agreement covers the risks and benefits of the prescribed weight loss approach, the importance of compliance with follow-up visits and lab monitoring, and the patient's commitment to the program. This medical weight management intake form reduces administrative burden, ensures consistent data collection, and sets the stage for a productive initial consultation.