Patient & Contact

Last name

First name

DOB

Street

City

State

Zip

Phone

Cell

Work

Email

Best contact method

Call Text Email

Emergency contact

Emergency phone

Primary care physician

PCP phone

How did you hear about us?

Google FB/IG Walk-in Referral

Referred by

Pharmacy

2

Past Medical History

Check all conditions reported (only checked items appear in the note) Cancer (type, if any) Other past medical history / notes

3

Surgical & Family History

Past Surgical History

Gallbladder Removal Weight Loss Surgery Pelvic surgeries

Other surgeries

Family History

Check each side affected for any condition. Leave a row blank for none.

Condition	Father's Side			Mother's Side			Sibling
Condition	Grandfather	Grandmother	Father	Grandfather	Grandmother	Mother	Sibling

4

Medications & Allergies

Takes NO prescription medications?

Yes No

Prescription medications

Herbal / vitamin supplements Other supplements

Drug Allergies

No known drug allergies?

Yes (NKDA) No

5

Gynecologic & Pregnancy History

Age period started

Age period ended

Periods

Pregnancy history N/A?

N/A Applies

Pregnant / could be / planning during treatment?

Yes No

# Births

Birth dates

Birth control / procedures Hysterectomy detail (when / partial-complete / why) GYN comments

6

Social History

Caffeine

Caffeine use (note cups/cans per day in detail field)

Alcohol

None Wine Beer Liquor

Tobacco

None Socially Former smoker Vapes

7

Review of Systems

WOMEN ONLY Check all symptoms reported

8

Weight History

Ideal weight

Highest weight

Lowest weight

How does weight affect life and health? First noticed weight gain

Ever gained >20 lb in <3 months?

Yes No

Weight 1 yr ago

5 yrs ago

10 yrs ago

Life events associated with weight gain Previous weight-loss programs tried Weight-loss medications tried (incl. GLP-1) Max weight loss & how achieved Greatest challenges with weight loss

Counseling/therapy for weight management?

Yes No

Emotional factors influence eating?

Yes No

9

Nutrition & Eating

Currently on a special diet?

Yes No

Diet detail / who prescribed / other

Eating Disorder Screen

Toggle any reported. Flags appear in note in section order.

Eating disorder detail / treatment dates

Eating Habits

Meals per day

Meals skipped

Snacking pattern Beverage notes (soda, juice, sweet tea, milk, etc.) Eating notes

10

Physical Activity & Sleep

Enjoys physical activity

Days/week mod-vigorous activity

Minutes per bout

Activities done regularly Barriers to activity Equipment / activities enjoyed (notes)

Sleep

Avg hours/night

Usual bedtime

Usual waking time

Night/shift work?

Yes No

Sleep concerns reported CPAP/BiPap device (if applicable)

11

Occupation, Home Life & Mental Health

# in household

Occupation

Good social support for lifestyle change?

Yes No

Support people / partner's attitude (notes)

Mental Health

Is stress a major problem?

Yes No

Healthy coping mechanisms?

Yes No

How they cope with stress

Considers self an "emotional eater"?

Yes No

Diagnosed mental health condition?

Yes No

Which condition(s)

Anxiety Depression Bipolar

Ever been to a counselor / mental health professional?

Yes No

Currently receiving counseling? (detail)

Safety Screen

Ever seriously thought about hurting self?

Yes No

Ever attempted suicide?

Yes No

12

Visit Details

Date completed

Completed/entered by

Attestation reviewed & signed by patient?

Yes Pending

Additional notes

13

Patient Visit Summary (PDF)

Builds the branded printable summary. Patient name, DOB and date pull from the top of this form. Fill only what applies. Use Generate Visit Summary PDF at the bottom of the note panel, then choose "Save as PDF" in the print dialog.

Sex

Age

Visit type

Provider (appears in header + visit details)

1 · Medical History Review

Narrative paragraph

2 · Vitals & Physical Findings

Add a callout for each finding. Status sets the color: Normal=green, Attention=amber, Elevated/Abnormal=red.

3 · Electrocardiogram (EKG)

Include EKG section?

Yes No

EKG status

EKG findings (one bullet per line)

4 · Laboratory Results & Interpretation

Add a callout per lab/finding (Triglycerides, LDL, Testosterone, A1c, etc.).

5 · Referrals

Intro line

Referral narrative bullets (one per line, optional)

6 · Cancer Screening

Screening recommendations (use a line starting with ## for a sub-heading; other lines become bullets)

7 · Vaccinations

Intro line

8 · Lifestyle & Wellness

Recommendations (## for sub-heading; other lines become bullets) Closing note (optional)

My Wellness Physicians

Lipedema & Lymphedema — History and Physical

Patient & Contact

Past Medical History

Surgical & Family History

Medications & Allergies

Gynecologic & Pregnancy History

Social History

Review of Systems

Weight History

Nutrition & Eating

Physical Activity & Sleep

Occupation, Home Life & Mental Health

Visit Details

Patient Visit Summary (PDF)

📋 CRM Note (auto-generated)