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Client
Compatibility Profile
Form Complete
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The client has not signed the waiver yet.
Name:
David
Maglangit
Email:
Best Contact Number:
(452) 154-8763
Referred By:
Gender:
Male
Birthday:
December 1, 2002
Age:
20
Address:
NE Twelfth St, Irrigon, OR 97844, USA
Weight History
When did you become overweight?
Did you ever gain more than 20 pounds in less than 3 months?
How long ago?
How much did you weigh a year ago?
How much did you weigh 5 years ago?
How much did you weigh 10 years ago?
Triggers for your weight gain (check all that apply):
Previous weight-loss programs (check all that apply):
Additional details of the triggers for your weight gain:
Please Specify Weight Loss Program:
What was your maximum weight loss?
What do you feel is your ideal or desired weight?
What are your greatest challenges with dieting?
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?
Average Frequency
What prevents you from exercising?
Are you pregnant or are you trying to become pregnant?
How many hours do you sleep at night?
Do you feel rested in the morning?
Please check if you are or have had any of the following (check all that apply):
Diabetes
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?
List of Medications Currently Taking
Do you have history of allergy to semaglutide or other glp-1?
No
Do you have allergies?
List of Patient Allergies
Viewing:
David Maglangit
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