Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Weight Loss Program Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Current Weight, Height & BMI
Medical Conditions Screening
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Known Allergies
| Allergy | Reaction |
|---|---|
Additional details
Diet History & Eating Patterns
Exercise & Physical Activity Level
Prior Weight Loss Programs Attempted
Weight Loss Goals & Motivation
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Emergency Contact
Name
Relationship
Phone
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Weight Loss Program Intake Form template from formisoft.com. formisoft.com/intake-templates/weight-loss-program-intake