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Online Patient Intake Form – Weight Loss Therapy

Personal Information
Full Name*
Date of Birth*
Height (Ft)*
Gender*
Current Weight (lbs)*
Desired Weight (lbs)*
Phone Number*
Email Address*
State*
City*
Fill required fields
Section 1: Weight History
How long have you been struggling with your weight?*
Have you tried dieting or exercise programs before? *
If yes, which ones?
Did you experience short-term or long-term success?*
Section 2: Metabolic & Physical Symptoms
(Check all that apply)*
Section 3: Lifestyle & Wellness
How many days per week do you exercise?*
How many hours of sleep do you get per night? *
Do you consume alcohol?*
Do you smoke or vape? *
Section 4: Hormonal & Emotional Health
Section 4: Hormonal & Emotional Health
(Check all that apply)*
Section 5: Medical History
Section 5: Medical History
Have you been diagnosed with any of the following? (Check all that apply)*
Section 6: What Are Your Goals With Treatment?
Check all that apply*
Consent & Acknowledgment
Consent & Acknowledgment*
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that this questionnaire is used to determine candidacy for NAD+ and peptide therapy and does not replace a medical diagnosis or physician consultation.
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