Complete Weight Loss and

Healthcare, LLC

​Phone: (205) 769-6032

Fax: (205) 769-6031

Patient Information

__________________________________________________________________________________________________

Have you ever taken or used prescription appetite suppressant?   Y / N     If so, what kind? _____________________________________

How long has it been since you last took an appetite suppressant? _____________________________________________________________

Goal Weight ____________________ lbs

What is your objective in loosing weight ? (health, appearance, other) _____________________________________

Do you smoke?  Y / N       If yes, how often? _______________________

Please clearly identify by circling each of the following if you have EVER had

     a.     MVP (Mitral Valve Prolapse)

     b.     Any type heart murmur

     c.     Hypertension or high blood pressure

     d.     Kidney Disease

     e.     Thyroid problems

     f.     Liver disease (hepatitis etc) or abnormal liver enzyme blood test

     g.     Diabetes

     h.     Glaucoma

     i.     Unprovoked rapid heart beats

     j.     Alcohol abuse / addiction

     k.     Involved in domestic violence or arrested for any type of violent behavior

     l.      Arrested, accused of or detained for anything involving illegal or controlled drugs

Please List all your drug allergies or intolerance

____________________________________________________________________________________________________________

Please record here all medications you are taking OR have taken within the last month

____________________________________  ______________________________________  ________________________________

____________________________________  ______________________________________  ________________________________

I agree to the following:

Never to share or sell any medication I receive by prescription from the clinic.

To protect these medications from possible accidental ingestion by children.

To promptly notify any physician of the medication I received from this clinic and the name of the medication.

To not become pregnant and if I risk pregnancy, to promptly stop taking these medicines.

That I have not taken medication known as a MAO inhibitor (a strong antidepressant)

That my answers to all the above questions are truthful and complete.

Signature   ________________________________________________________              Date _________________________

Office Staff Signature _____________________________________________                                                                    Page 2