Weight Loss Intake

Tell us a bit about your weight history, goals, and what you've tried. Your provider will review this before your visit.

Candidacy for any treatment — including GLP-1 medications — is a clinical determination. Outcomes are not guaranteed.

Height (e.g., 5'9")

Current weight

lbs

Goal weight

lbs

Highest adult weight

lbs

What have you tried in the past? (diets, programs, medications, surgery)

Do you have diabetes, prediabetes, high blood pressure, thyroid issues, PCOS, sleep apnea, or fatty liver?

Current medications and supplements

Have you ever used a GLP-1 medication (Ozempic, Wegovy, Mounjaro, Zepbound, etc.)?

Typical weekly activity / exercise

Average sleep per night

Alcohol use (drinks per week)

What is most important to you about this? (health, energy, mobility, appearance, specific event)

Your Information

So we can match this to your chart and follow up.

Full name *Email *PhoneDate of birthAnything you'd like the provider to know?

Submitted securely. Used only for your care.

A-Nu Health · (312) 796-2646 · info@a-nuhealth.com — These responses are informational and reviewed by your provider. Not a diagnosis. If you are in crisis, call or text 988 or call 911.