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Health Measurements Form

Medical Form

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First Name

Last Name

Date of birth

Gender

Height (cm):

Weight (kg):

BMI

General Practitioner's Name:

General Practitioner's Number:

General Practitioner's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Medical History Questions

Do you have any of the following medical conditions? (Tick all that apply) :

Have you ever been diagnosed with depression, anxiety, or another mental health condition? :

Yes

Are you currently taking any prescription medications, herbal supplements, or over-the-counter drugs? :

Yes

If yes, please list the medicines or other drugs you are taking.:

Do you have any known drug allergies? :

Yes

If yes, please list the medicines or other drugs you are taking.:

Have you previously tried to lose weight through diet and exercise? :

Yes

Have you used any weight loss medications before? :

Yes

Do you smoke or consume alcohol regularly? :

Yes

What areas of your body are you looking to improve? :

Are you currently pregnant, planning to become pregnant, or breastfeeding? :

Yes

Have you had any weight loss surgery (e.g., gastric bypass, gastric sleeve)? :

Yes

Have you ever experienced unexplained weight loss? :

Yes

Have you ever had pancreatitis? :

Yes

Why do you wish to lose weight? :

Please share any specific concerns or goals you’d like to discuss.:

Agreement

By submitting this form, I confirm that:: The information I have provided is accurate., I understand that weight loss medications are not a substitute for diet and exercise., I agree to seek medical advice if I experience any side effects., I consent to my information being reviewed by a registered healthcare professional.

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Health Measurements Form

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