13577 Feather Sound Dr., Suite 350 Clearwater, FL 33762 Call us at: +727 571 1923 Text us at: +727 263 4798 info@skinspirations.com

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Weight Loss Questionnaire

Home / Weight Loss Questionnaire

Weight Loss Questionnaire

"*" indicates required fields

First name*

Last name*

Date of birth

Email address*

Street address*

Apartment or unit number

City*

State*

Zip Code*

Phone number*

How did you hear about us?*

Name of person who referred you

Medical History

Please list any allergies to medications below.

I have no known allergies

My allergies are:

Do you smoke cigarettes or have you smoked in the last six months?

Yes

No

Have you or any family members ever had thyroid cancer or multiple endocrine neoplasia (MEN)?

Yes

No

Please check any medical conditions for which you've been diagnosed.

Anxiety or depression

Asthma or chronic bronchitis

Autoimmune or connective tissue disease (please specify type below)

Bleeding disorder (please specify type below)

Cancer (please specify type below)

Gallstones

Diabetes type I

Heart Disease or arrhythmia

Hepatitis B or C

HIV

Pancreatitis

Hypertension

Neurological disease or event (please specify type below)

Ovarian cysts

Thyroid disease or nodules (please specify type below)

Other (please specify type below)

Type of condition checked above

Please list any prescription medications you're taking.

Please list any surgeries you've undergone.

How tall are you?*

What is your current weight, roughly?*

What is the most you've ever weighed?

What is your weight pattern?

Stable

Fluctuates up and down

Progressively increasing

On average, how many days per week do you get at least 30 minutes of exercise?

Please check the type of diet you usually follow.

General

Low carbohydrate

Low fat

Vegetarian

Vegan

Raw, plant-based

Non-dairy

No processed foods

No red meat

Check off any of the following eating patterns you have.

Night snacking mostly

Snacking all day

Crave sugar or salty foods

Often have second helpings or large food portions.

Eat a lot of processed foods

Eat fast food at least once a week

Always hungry

Eat more when bored or stressed

If you've had your HbA1c checked with blood work in the last 3 months, what was the value? (leave blank if you haven't)

Which of the following weight loss programs do you prefer?

Office visits every 6 weeks with self-administered skin injections weekly

Weekly visits to have injections done in our office

Not sure yet

How do you prefer we contact you when we check on your progress?

Phone call

Text

Email

When is the best time of day to contact you?

Name

This field is for validation purposes and should be left unchanged.

Skinspirations

Main Office 13577 Feather Sound Drive, Suite #350 Clearwater, Florida 33762 727.571.1923 727.263.4798
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Please Note: Procedure results vary greatly from patient to patient and are not guaranteed. The photos on this website are not intended to represent the results that every patient can expect. The information on this site is intended for general purposes only and is not intended to nor implied to be a substitute for professional medical advice relative to specific medical conditions or questions.