Medical Weight Clinic Patient Intake Form
Patient Information
Name: ____________________________________________________________
Address: __________________________________________________________
Birth Date: ________________________________________________________
Marital Status (circle) Single Married Divorced Widow
City / State / Zip: ___________________________________________________
Home Phone: ______________________________________________________
Mobile Phone: _____________________________________________________
Email Address: _____________________________________________________
What treatments are you interested in pursuing?
□ Lifestyle changes and weight loss medications
□ Lifestyle changes and weight loss supplements
Overall Goals:
□ No weight goal, only to feel better. Yes / No
□ No weight goal, improvement in ______________________
□ Weight goal of ___________ lbs.
Normal weight during childhood? □ Yes □ No
Highest adult weight lbs. Lowest adult weight_____________ lbs.
Lowest adult weight on a diet or weight loss program______________ lbs.
Goal weight____________ lbs.
Are there any other reasons for weight gain?
Answer any that apply.
Shift work with associated weight gain of__________ lbs.
I quit smoking with associated weight gain of_________ lbs.
Past or present medications associated with weight gain of__________ lbs.
Female Patients Only:
I have postpartum weight retention of
I have menopause associated with weight gain of lbs.
Diet History
What diets have worked for you in the past?
Please list all that apply. _____________________________
_____________________________
_____________________________
What is the most weight that you have lost __________ lbs.
How long did you maintain that weight loss?_________
Are you currently working with a Registered Dietitian? □ Yes □ No
I exercise: ______________________ mins/hours ______________ times a week.
Type of exercise that I have most often done __________
My weight limits my exercising. Yes / No
Pain limits my exercising. Yes / No
I drink _____________ ounces of water daily.
I have been unable to exercise because: _____________________________________
I sleep an average of ___________________ hours at night.
Medical History
Female patients only:
Date of last period
Current contraceptive/Birth control use:
Oral contraception __________________ IUD (Intrauterine device) ______________________
Tubal ligation (tubes tied) ____________ Hysterectomy and/or ovaries removed ____________
Other ____________
History of Glaucoma? □ Yes □ No
History of Palpitations? □ Yes □ No
History of Chest pain? □ Yes □ No
History of Headaches? □ Yes □ No
History of Kidney Stones? □ Yes □ No
History of Seizures? □ Yes □ No
History of Head trauma? □ Yes □ No
History of radiation to the brain? □ Yes □ No
History of Pancreatitis? □ Yes □ No
History of Diabetes? □ Yes □ No
History of Hypertension (high blood pressure)? □ Yes □ No
History of Hyperlipidemia (high cholesterol)? □ Yes □ No
Personal or family history of thyroid cancer? □ Yes □ No
Past weight loss surgeries: _________________________
Other: ______________________________________________
Medication History
Do you have any allergies: ________________________________________
Please list all current medications: __________________________________
What weight loss medications have you tried in the past:
Weight loss Drug(s) ______________________________________________
Amount of weight loss ___________________________________________
Side-effects _____________________________________________________
Pay for Services
Our office is a pay-for-service office. Some insurance carriers may start covering services and if they do,
we will inform you and additional authorizations will be required. If labs are required, you may use your
insurance with our contracted lab, Foundation Lab. However, if your insurance carrier denies coverage
for laboratory work, our office will bill you.
Please read and check each item below:
___I understand that Steven M. Kaye, MD, Inc. does not provide primary care.
___I understand that there are no guarantees of a specific weight loss amount and that medical
weight loss results vary between individuals depending on initial weight, medical conditions,
individual responsiveness to medications, and adherence to treatment plans.
Patient Signature: __________________________________________________________
Print Name: _______________________________________________________________
Date: ____________________________________________________________________
"By providing a telephone number and submitting the form you are consenting to be contacted by
SMS text message from (Bakersfield Weight and Wellness). Message frequency may vary. Message
& data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more
information. See our Privacy Policy (https://mdwnw.com/privacy-policy/)"
Steven M. Kaye, MD, Inc.
1701 Westwind Drive | Suite 217 | Bakersfield, California 93301 661-758-4400
| bf.info@mdwnw.com