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Clinical Assessment Form
Premier Medical Management 801 Travis st ste. 2101 #TBD
WEIGHT MANAGEMENT (Semaglutide) MEDICAL HISTORY FORM
Name
Address including City, State and Zip Code
Home Phone
Cell Phone
Email
Date of Birth
Age
Gender
Male
Female
Driver’s License #
State Issued
Exp
Occupation
Marital Status
Emergency Contact Name
Address including City, State and Zip Code
Phone
WEIGHT MANAGEMENT MEDICAL HISTORY FORM
Doctor’s Name
Phone
Location
QUESTIONS
What is your purpose for weight loss treatment?
What is the reason you want to lose weight?
How long has your weight been a problem?
Are you currently at your heaviest weight? Yes or No (If no, how much did you weigh at your heaviest weight?)
My worst food habit is...
What methods have you previously tried to lose weight?
Are you a stress eater?
Yes
No
Do you eat in the middle of the night?
Yes
No
Does your significant other struggle with weight issues?
Yes
No
Are you scared of needles/needle phobic/faint easily when you have blood taken?
Yes
No
WOMEN ONLY
Are you trying to achieve pregnancy or planning pregnancy in the near future?
Yes
No
Are you or could you be pregnant? q Are you breastfeeding?
Yes
No
Are you on any type of hormone replacement therapy?
Yes
No
Are you using any type of contraceptives (birth control)?
Yes
No
Medications:
Please list all prescription medications you currently take, including samples. Medication Name Dose Number of times per day Doctor
Herbal/Supplements: Please list all vitamins, herbs, enzymes, protein supplements, pro-hormones or any other supplements.
Date of last complete physical exam
Circle Correct Answer
Normal
Abnormal
Circle Correct Answer
Never
Can’t Remember
List any other medical or diagnostic test you have had in the past two years
List hospitalizations, including dates and reasons for hospitalization (including surgeries)
Allergies
Please list medications, food, or environmental allergies and what reactions have occurred (if any)
Please check all that apply to you
Heart Disease (heart attack
Diseases of the arteries
High blood cholesterol
Anemia or other blood disorders (i.e. Sickle cell disease
History of dizziness
Medullary thyroid cancer
Thyroid disease/problems
Parathyroid problems/Adrenal gland problems
Diabetes or abnormal blood-sugar tests
Phlebitis (inflammation of a vein)
Deep vein thrombosis/blood clot in the leg (DVT) or PE (pulmonary embolism)
Gallstones or any gallbladder disease (including jaundice)
High blood pressure (Hypertension)
Severe reflux
Any breathing problems (such as asthma, COPD, bronchitis)
Infective endocarditis
Kidney problems including Chronic Kidney disease (CKD)
Pancreas/digestion problems (including acute or chronic pancreatitis)
Stomach/duodenumigastric ulcer
Liver problems (including hepatitis, liver failure, fatty liver, alcoholic liver disease)
Any neurological problems (including Parkinson Disease)
Severe stomach/gut problems (incl. inflammatory bowel disease: Crohn’s disease or Ulcerative colitis)
Irritable bowel syndrome (IBS)
Jaundice or gall bladder problems
Skin conditions
Eating disorder (such as anorexia or bulimia)
Mental health problems (including personality disorder, psychosis. diagnosis of depression)
Self-diagnosis of depression, low mood, nervous or emotional problems Substance abuse (including alcohol or drugs)
Are you on any blood thinners?
Yes
No
Do you or have you ever smoked?
Yes
No
Weekly alcohol intake?
Do any of the discussed contraindications apply to you?
Yes
No
At this time, my current exercise routine includes...
Circle only those questions to which you answer "Yes"
Heart attacks under age 50
Strokes under age 50
High blood pressure
Elevated cholesterol
Diabetes
Asthma or hay fever
Skin allergies
Congenital heart disease (existing at birth but not hereditary)
Heart operations
Red blood cell disorders i.e. Sickle Cell, Thalassemia, and Anemia
Glaucoma
Kidney Disease
Obesity (20 or more pounds overweight)
Leukemia or cancer under age 60
Physician Signature
Clear
Nurse Signature
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