Weight Loss Intake Forms - Cardea Health Integrative

Do you suffer from any of the following? (Check all that apply)

Taking Insulin
Stroke history
Multiple Endocrine Neoplasia Syndrome Type 2 MEN 2
Pancreatitis or gallbladder disease
Chronic kidney disease
Type 1 Diabetes
Heart attack history
Medication allergies
Other medical issues not listed
Any family members with MEN2?
None

Tell us a little about yourself.

Name

First

Last

Date of Birth

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

What is your current weight?

How tall are you?

What is your weight loss goal?

Have you previously struggled to lose weight?

Do you feel that you have control over your eating habits?

Never
Rarely
Sometimes
Frequently

Do you have any of these?

High blood pressure
High blood pressure medication
High cholesterol
High homocysteine
Other weight issues
None of these

Have you ever taken these peptides? If yes, which ones?

Semiglutide
CJC1295
Ipamorelin
Tirzepatide
None of these

Have you taken any of these?

Ozembic
Wagovia
None of these

Please list all the supplements and medications you are currently taking.

Thank you for providing this information*.

It will help us to help you succeed in reaching your healthy goal weight.

Cardea Health Integrative (CHI) does not view or discuss Protected Health Information (PHI) or Confidential Information in public areas even if specifics such as patient's name are not used. CHI does not make any unauthorized transmissions, copies, disclosures, inquiries, or modifications of PHI or Confidential Information. Any PHI submitted herein is secure and protected per HIPAA privacy laws.

Is there any other health information you would like to share? It will enable us to provide you with optimal, personalized care specific to your needs.

We recommend a healthy lifestyle and an exercise program to enhance your treatment, using Semaglutide. If you have other physicians providing your care, please discuss the use of this peptide with them as well.

Semaglutide is a peptide and it is quite effective and works efficiently for weight loss. You agree to receive this treatment from just one provider at a time and we will give you detailed instructions about the use and care of this treatment.

With your submission, you agree to accept this consult and terms and conditions.

Please upload a Photo ID to participate in this treatment plan.

Click or drag a file to this area to upload.

Congratulations! You have completed all the requirements so far. Next steps will be to schedule and pay for the first month of your weight loss journey.

We will be in contact within 2 business days. If you prefer to contact us, please see below:

Email: admin@cardeahealthwny.com

Phone: 716.685.2361