ealthsmart
WEIGHT LOSS &
GYNECOLOGY

(636) 333-1614

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8 am - 5:30 pm

Friday
8 am - 12 pm

Saturday
8 am - 12:30 pm

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Weight Loss Evaluation

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Weight Loss Program: Initial Evaluation

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Name
First Last
Age
Current Weight
BMI
Weight Goal
Email
Gym Membership
- Yes
- No
IPhone/Kindle/Android/Smart Phone
- Yes
- No
Marital Status
- Married
- Single
Current Medical Problems
Employed
- Yes
- No
Initial evaluation questionnaire
Have you tried to lose weight over past six months and been unsuccessful in achieving your goals?
- Yes
- No
Do you have any of the following?
Hypersensitivity to phentermine or other amphetamines?
- Yes
- No
Family history of diabetes?
- Yes
- No
Do you smoke?
- Yes
- No
Family history of high cholesterol?
- Yes
- No
Advanced arteriosclerosis?
- Yes
- No
Advanced cardiovascular disease?
- Yes
- No
Moderate to severe hypertension?
- Yes
- No
Pulmonary Hypertension?
- Yes
- No
Untreated hyperthyroidism?
- Yes
- No
Have you ever been tested for hypothyroidism?
- Yes
- No
If Yes, Date Tested
MM slash DD slash YYYY
Results
- Normal
- Abnormal
Glaucoma?
- Yes
- No
History of drug abuse?
- Yes
- No
Currently taking any drugs classified as an MAO inhibitor?
- Yes
- No
Do you see a physician regularly?
- Yes
- No
Do you suffer from depression or anxiety?
- Yes
- No
Do you consider yourself an emotional eater?
- Yes
- No
Borderline diabetes?
- Yes
- No
High cholesterol?
- Yes
- No
Are you currently taking any prescribed medications?
- Yes
- No
List of Medications
Name When Taken
What did you eat yesterday for:
Breakfast
Lunch
Dinner
Snacks
Insurance Information
Insurance Company Name
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Phone
Insurance ID Number
Cardholder Name
First Last
Cardholder DOB