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Client
Compatibility Profile

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Profile Default.jpg

Name:

Jamie

Eagen

Email:

Best Contact Number:

(810) 434-4727

Referred By:

Kellee Ostrander

Gender:

Female

Birthday:

February 17, 1957

Age:

67

Address:

130 Fox Glen Dr, Naples, FL 34104, USA

Weight History

When did you become overweight?

Childhood

Did you ever gain more than 20 pounds in less than 3 months?

No

How long ago?

How much did you weigh a year ago?

190

How much did you weigh 5 years ago?

170

How much did you weigh 10 years ago?

170

Triggers for your weight gain (check all that apply):

Stress, Menopause

Previous weight-loss programs (check all that apply):

Weight Watchers, South Beach, Keto

Additional details of the triggers for your weight gain:

Boredom

Please Specify Weight Loss Program:

What was your maximum weight loss?

20 lbs

What do you feel is your ideal or desired weight?

150

What are your greatest challenges with dieting?

Late night snacking

Have you ever taken any of these medications? (check all that apply):

What worked?

Please specify medication

Did it work?

Medical History

Do you exercise?

Yes

Average Frequency

What prevents you from exercising?

Are you pregnant or are you trying to become pregnant?

No

How many hours do you sleep at night?

8

Do you feel rested in the morning?

Yes

Please check if you are or have had any of the following (check all that apply):

Indigestion/reflux

Please specify disease

Do you still have cancer?

Have you ever been diagnosed with an eating disorder?

No

Is it anorexia?

Are you currently taking diuretics?

No

Past surgical history (check all that apply):

Please specify surgery

Are you currently taking any medication?

No

List of Medications Currently Taking

Do you have history of allergy to semaglutide or other glp-1?

No

Do you have allergies?

Yes

List of Patient Allergies

Asa
Codeine

Viewing:

Jamie Eagen

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