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Begin Your Weight-Loss Intake

Complete the secure intake below to help your Nurse Practitioner determine the safest and most effective next steps.

What is your height and weight?

Feet
Inches
Are you male or female?
Male
Female
What is Your Date of Birth?
Month
Day
Year
Questions 1: Do any of these apply to you?
Questions 2: Do any of these apply to you?
Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?
Yes
No
Have you had prior weight loss surgeries?
Yes
No
Do you currently take any medications?
Yes
No
Do you currently take any medications?
What is your average resting heart rate?
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