Anchor Medical Weight Loss
Application Form

Semaglutide

Tirzepatide

Phentermine

Ozempic | Wegovy | Zepbound

Contrave

Injectable Nutrients

Weight Loss

Anchor Medical Weight Loss Application Form

Welcome!

Dear valued customer, we’re delighted to have you on board. To ensure we make the most of your upcoming appointment, we kindly ask you to complete the Anchor Medical Weight Loss Application form. Your information is crucial for us to understand your concerns better and tailor our discussion during your appointment.

Please take a moment to fill out the form. Your patience and cooperation are highly appreciated.

Thank you!

Anchor Medical Weight Loss Application Form

Anchor Medical Weight Loss RegistrationForm

Please complete the form and book your appointment online.

Thank you.

Personal Information

First Name

Last Name

Sex

Male

Female

Date of Birth

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Your Primary Care Physician

Your PCP Phone

Your PCP Address

How did you hear about us?

Friend/Family

Search Engine : Google etc

Instagram

Tiktok

Facebook

Groupon

Others

If others, please specify

Medical History I

Allergies (Medications/Food/Environments)

Surgeries

Gastri bypass

Gastric banding

Gastric Sleeve

Gall Bladder

Heart bypass

Hysterectomy

Others

If others, please specify surgeries which you had or are receiving

Medications (List all current medications, dosages, and frequencies)

Dietary supplements or Vitamins

Social History

Tabacco Smoking:

Never

Current Smoker

Former Smoker

If current/former smoker, please specify how many packs/day or quit how long ago?

Alcohol:

Never

Occasional

Regularly

Alcoholism

If checked, please specify how many drinks per day

Drug:

Never

Current

Past

If checked, what type of drugs

Marijuana

Never

Current

Past

If checked, please specify how many times per day?

Family Medical History

Please checked, if you or any member of your family have any following

None

Diabetes Type I or II

Hypertension > 180/100

High Cholestrol

Heart disease / Pacemaker / Defibrillator

Kidney disease / Chronic kidney disease

Lung disease / Asthma / COPD

alcoholic liver disease / Hepatitis / Fatty liver

Thyroid disorder / Medullary thyroid cancer

Pancreatic disorder

Parathyroid / Adrenal gland problem

Gallbladder disease

Gastric / Bowel disorder

Acid reflux / Constipation

Fibroids / Ovarian cysts / PCOS

Infertility

Blood disorder / DVTs / Pulmonary Embolism

Multiple Endocrine Neoplasia Type II

Endocrine disorder

Seizures / Stroke

Neurological problem / Parkinson disease

Multiple sclerosis

Anxiety / Depression

Personality disorder / psychosis

Sleep apnea

Bipolar disorder

Cancer / Chemotherapy / Radiation therapy

Leg Cramps / Gout / Arthristis

Obesity

Others

If checked, please explain

Weight History

Current Weight (lb)

Goal Weight (lb)

Are you stress eater?

Yes

Do you eat in the middle of the night?

Yes

How does your weight affect your life and health?

When did you become overweight?

Childhood

Teens

Adulthood

Pregnancy

Menopause

Did you ever gain more than 20 lb in less than 3 months? if so, how long ago?

Have you ever been diagnosed with an eating disorder? if yes, how long ago?

Triggers for your weight gain (check all that apply)

Stress

Marriage

Divorce

Illness

Medication effects

Travel

Injury

Nightshift work

insomnia

Quitting smoking/Alcohol/Drugs

Others

If others, please specify

Previous weight-loss programs (check all that apply)

None

Weight Watchers

Nutrisystem

LA Weight Loss

Atkins

DASH diet

HCG diet

Keto diet

Mediterranean diet

Others

If others, please specify what methods have your tried to lose weight?

Have you ever taken medication to lose weight?

None

Phentermine (Adipex)

Ozempic

Wegoovy

Saxenda

Qsymia

Contrave

Topamax

Bupropion (Wellbutrin)

Others

Which medication works, why?

Female questions

Age periods started

Age periods ended

Periods

Regular

Irregular

----

Heavy

Normal

Light

# of pregnancies

# of children

Are you pregnant or trying to get pregnant soon?

Yes

Are you on any contraceptive methods?

Yes

Are you or have you been on any type of hormone replacement therapy?

Yes

Weight History

Current weight (lb)

Goal weight (lb)

How does your weight affect your life and health?

When did you become overweight?

Childhood

Teen

Adulthood

Pregnancy

Menopause

Did you ever gain more than 20 lbs in less than 3 months? if so , how long ago?

Have you ever been diagnosed with an eating disorder? If so, which one? how long ago?

Triggers for your weightgain?

Stress

Marriage

Divorce

Illness

Medication side effects

Travel

Injury

Nightshift work

Insomnia

Quitting smoking/Alcohol/Drugs

Previous weight-loss programs?

Weight watchers

Nutrisystem

LA weight loss

Atkins

DASH diet

HCG diet

Keto diet

Mediterranean diet

Others

If others, please specify

Are you a stress eater?

Yes

Do you eat in the middle of night?

Yes

What method have you tried to lose weight?

Have you ever taken medication to lose weight? (Check all that apply)

Phentermine (Adipex)

Ozempic

Wegovy

Saxenda

Qsymia

Contrave

Topamax

Bupropion (Wellbutrin)

Others

Which medication worked, why?

Nutritional History

How often do you eat breakfast: days per week at what time?

# of meas you eat per day?

Do you get up at night to eat? if so, how often times per day?

Food craving (Check all that apply)

Sweets

Chocolate

Carbs/Starches

Salt

High fat

Large portions

Soda

Energy drinks

Coffee

Favorite foods

Please specify your favorite foods

Food Triggers (Check all that apply)

Stress

Boredom

Anger

Seeking reward

Parties

Eating out

Fast food

Other

If others, please specify

Exercise

Exercise type

Duration: _____ hours _______ minutes

# of days per week

What prevent you from exercising?

How many hours do you sleep per night?

Do you feel rested in the morning? (Y/N)

Please book your appointment!

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