Weight Loss Questionnaire

"*" indicates required fields

Today's date*
Date of birth (required by pharmacy)*

Medical History

Please list any allergies to medications below.*
Do you smoke cigarettes or have you smoked in the last six months?
Have you or any family members ever had thyroid cancer or multiple endocrine neoplasia (MEN)?
Please check any medical conditions for which you've been diagnosed.
What is your weight pattern?
Please check the type of diet you usually follow.
Check off any of the following eating patterns you have.
Which of the following weight loss programs do you prefer?
How do you prefer we contact you when we check on your progress?
This field is for validation purposes and should be left unchanged.