Health History Intake Form – WildBerryMD Telehealth

Phone

This field is for validation purposes and should be left unchanged.

Personal Information

Full Name*

Email*

Phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth*

Gender*

Male

Female

Other

Height

Feet*

Inches*

Weight*

How Did you hear about us?

Emergency Contact Name & Phone

Name*

Phone*

Consent to receive automated messages/reminders:

Texts

Calls

E-mails

Food/Medication Allergies?*

No

Yes

List of Allergies*

Pregnant or breastfeeding?

No

Yes

Current medications or supplements?*

No

Yes

Current medications or supplements List*

Past use of weight loss meds (e.g., phentermine, GLP-1, bupropion, other)?*

No

Yes

Past use of weight loss meds List*

Surgical History*

No surgeries

Yes

Type / Date of Surgery*

Family Medical History (Check applicable family members only)

Father

Mother

Siblings

Lifestyle & Goals

Do you have any Weight Loss Goals?

Do you have any Hormone Balance Goals?

What Program or Service are you interested in?

What are you struggling with?*

(e.g. hunger, cravings, hormone balance, menopause, pre-menopause, mood swings, irritability, low Testosterone, difficulty losing weight, bloated belly, low energy, loss of muscle mass, lack of motivation to get started, meal planning, other?

Alcohol use?*

No

Occasionally

Frequently

Drinks / Week*

Tobacco use?*

No

Yes

Packs/day*

Recreational/illicit drug use (past or present)?*

No

Yes

Type*

Primary weight loss goals:*

Lose weight/fat

Improve energy

Curb appetite/cravings

Improve blood sugar

Boost confidence/appearance

Other

Other Primary weight loss goals*

Date of Form Completion*

CAPTCHA