Hormone Fitness Intake Form

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Intake Forms
New GLP-1 Patient
General Information
Full Name*
First NameLast Name
Phone Number*
mobile
Email Address*
Date of Birth
MonthDayYear
Gender (assigned at birth):*
MaleFemale
Are you currently pregnant, nursing, or trying to conceive?
YesNo
Mailing Address*
Street Address
Street Address Line 2
CityState
Zip Code

Medical Information
Height -> feet*
ft
Height -> inches*
ft
Current weight:*
lbs
Total Height (in)
Check the conditions that apply to you or your immediate family members:*
AnxietyAsthmaCancerCardiac DiseaseDepressionDifficulty with Regulating Blood SugarFatty Liver DiseaseHeart DiseaseHepatitisHigh CholesterolHIVHypertensionHypoglycemiaKidney DiseasePancreatic ProblemsPCOSPreDiabetesShortness of BreathType I DiabetesType II DiabetesNone
Do you or any of your family members have a history of any of the following:*
Multiple Endocrine Neoplasia type IIThyroid cancerBothNeither
Do you have a hypersensitivity to Semaglutide?*
YESNO
Are you currently taking insulin or other insulin-releasing medications?*
YESNO
Are you currently taking any medications?*
YESNO
Please list all medications your currently taking:
Do you have any medication allergies?*
YESNO
Please list all medications allergies:
Have you had any hospitalizations or surgeries?

A Warm Welcome to Hormone Fitness!
-> Your weight loss journey starts NOW!
Would you like to set a "Goal Weight" for your GLP-1 treatments?*
YESNO
Great! Please set your goal weight:
lbs
Goal Weight - Text
BMI- Text
Current Weight Text
Goal BMI Text
Are you currently planning or considering making any lifestyle changes while using GLP-1 medications?
YESNO
Good for you! Select all that apply:
Diet PlanningExercise RoutineOther
Current Weight
Goal Weight
lbs
lbs
Your Current BMI is
Your Goal BMI is

Emergency Contact (required)
Full Name*
emergency contact
Relation to you*
Phone Number:*
emergency contact
Email Address:*
emergency contact
Primary Care Provider (optional)
Your Provider
Phone (Office)
PCP Address*
Street Address
Street Address Line 2
CityState
Zip Code

Patient Consent
Your Signature*
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