Weight Loss Patient IntakeWe want to make it as easy as possible for you to achieve your optimal health.Please enable JavaScript in your browser to complete this form.1PERSONAL INFORMATION2MEDICAL HISTORY3Please rate on a scale of 1-10 (1 being the lowest and 10 being the highest)4For Office UseName *Date *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Cell) *Email *Date of Birth *Age *Height *Estimated Weight *Ideal Weight *NextDo you have/had any of the following? CancerHeart DiseaseThyroid DiseaseGallbladder DiseaseFatty Liver DiseaseLiver CirrhosisKidney DiseaseCholecystitisHIV/AIDSDiabetesHepatitis C or DAnemiaHigh Blood PressureIntestine ProblemsShortness of BreathHigh CholesterolHeadacheNeuropathy/Nerve problemsPoor SleepDizzinessArthritisWeight gainBack PainFatigueNo I have/had nothing above of themDo your family member have/had any of the following? (copy)CancerHeart DiseaseThyroid DiseaseGallbladder DiseaseFatty Liver DiseaseLiver CirrhosisKidney DiseaseCholecystitisHIV/AIDSDiabetesHepatitis C or DAnemiaHigh Blood PressureIntestine ProblemsShortness of BreathHigh CholesterolHeadacheNeuropathy/Nerve problemsPoor SleepDizzinessArthritisWeight gainBack PainFatigueNo they have/had nothing above of themAre you taking any medications/supplements?NoYesPlease provide listAre you pregnant, breastfeeding, or have active cancer?NoYesPlease tell us detailsAny known Shellfish allergies?How have you addressed weight management in the past? MedicationsVitaminsExerciseDiet and NutritionOtherOtherHow did the previous methods work for you?I am interested in *Weight lossInch LossAnti-AgingMetabolism SupportLong Term ResultsCollagen ProductionNextSelf-Image Selected Value: 1Energy Level Selected Value: 1Quality of Sleep Selected Value: 1How Important It Is For You To Resolve Your Health Concerns Selected Value: 1This consent to treatment form explains the risks and benefits of the Contour Light treatments. Patient understands the following:1. Results vary greatly from person to person. No result is guaranteed. 2. Contour Light is a treatment intended to be implemented in conjunction with a modification in diet and lifestyle as part of a complete protocol. The recommended diet and lifestyle is a critical part of the program and are essential in achieving the maximum results. 3. Temporary hyper pigmentation/hypo pigmentation (changes in skin color) on rare occasion may occur as a result of treatment.SIGNATUREBy signing below, patient agrees that provider listed above may perform the Contour Light procedure for the purpose of body contouring. Patient understands and accepts the risks listed above and agrees that all information provided on this form is true and correct to the best of patient’s knowledge.Print Name *Date *Patient Signature *NextWeightBMIBody Fat %Skeletal Muscle %Body AgeResting MetabolismVisceral Fat LevelSubmit
