Holistic Treatments and Integrative Medicine Center
Name
Date
Current Weight
Target Weight
Why do you want to achieve your target weight?(Please be Detailed)
How long has this been your goal?
Who else does this goal affect?
Are you ready for a change and need help?YesNo
What have you tried in the past to lose weight? (please list all starting with current or most recent)
Medical Weight Loss Transformation Information
If accepted for our program, will you take prescribed medications and follow all protocols and advice given to ensure your results? YesNo
Signature
Patients Medical contact and Date:
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