Home Appointment Form Appointment Form Telehealth Weight Loss Practice - Comprehensive Intake Form Personal Information Full Name Date of Birth Gender MaleFemaleOtherPrefer not to say Address Phone Numbe Email Address Health and Medical History Height Current Weight Target Weight (if known) Blood Type (if known) Primary Physician's Name Health Insurance Provider (if applicable) Medical History (Please check all that apply and provide details if necessary)DiabetesHeart DiseaseHigh Blood PressureHigh CholesterolThyroid DisorderGastrointestinal IssuesArthritisMental Health DisordersSleep ApneaOther Medications and Supplements (List any medications or supplements you are currently taking) Allergies and Intolerances (List any known allergies or intolerances, particularly food-related) Family Medical History (List any relevant family medical history, such as heart disease, diabetes, etc.) Lifestyle Information Occupation Average Daily Physical Activity LevelSedentaryLightly ActiveModerately ActiveAverage Daily Physical Activity Level Exercise Routine DetailsFrequencyTypeDuration Dietary HabitsRegularVegetarianVeganGluten-FreeKetoOther Average Daily Water Intake Sleep Patterns:(Average hours per night, any sleep issues) Weight Loss History Previous Weight Loss Attempts: (Details about diet plans, programs, and their outcomes) Challenges Faced in Previous Attempts: (e.g., motivation, diet, exercise) Goals and Motivation Primary Goals for Joining the Program: (e.g., weight loss, fitness improvement, better nutrition) Short-term Goals: (Next 3 months) Long-term Goals: (Next 6 months to a year) Consent and Acknowledgement I hereby confirm that the information provided is accurate to the best of my knowledge. I understand this information will be used to guide my wellness and weight loss plan. I consent to receive telehealth services from [Enspire Healthcare ]. [/acceptance]
