Name * First Name Last Name Email * Dropdown * Marital Status Single Married Divorced Seperated Widowed Age * Sex * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Occupation * How did you hear about us? * What are you hoping to achieve with our with our help with your weight and health? * Do you have insurance? * Do you have a Primary Care Provider? * Current Height? * Current Weight? * Waist Circumference in inches? Are these numbers measured recently or estimates? * What types of medical problems do you usually see a physician for? Please list all significant conditions: * Do you see a specialist for any medical conditions and if so, which ones and what type of specalists? * When was the last time you saw a physician and what was it for? * What medications do you take? * I understand this is a telehealth practice only with NO in person visits (unless discussed specifically)? * Yes No I understand that this is a self-pay only practice, that does NOT take insurance * Yes No Thank you!
