TeleMed – Initial Visit – Weight Management & Med Spa

Hayes Clinic & Spa

Patient Information & Medical History

Date

Appointment Date

Date of your appointment

Patient Name

First

Last

Date of Birth

Sex

Email

Primary Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Medical History

Primary Care Provider:

Current/Recent medications:

Pharmacy:

Please list any allergies including drugs:

Please check if you have any of the following:

Other:

Date of Last EKG/Stress Test:

Past Medical History & Surgeries:

Are you pregnant or breastfeeding?

Immunizations:

Last Physical Exam:

Last Lab Work:

Date of Last Colonoscopy:

Date of Last Pap Smear:

Date of Last Bone Density:

Date of Mammogram:

Family Health History:

Mother (Please check all that is applicable):

Father (Please check all that is applicable):

Social History:

Do you use tobacco products?

What kind and how much?

Do you consume alcohol?

What kind and how much/often?

What is your goal weight?

Estimated current exercise level:

None
Low
Medium
High

How many meals do you usually eat each day?

How many times a week do you eat out?

About how many 12 oz cans of soda do you drink in a day?

How many glasses of sweetened tea/coffee do you drink in a day?

How many 8 oz glasses of water do you drink each day?

Do you eat when you are bored?

If yes, what do you usually eat when you are bored?

Do you binge eat?

Example: Feel compelled to eat because of stress.

Have you ever used laxatives, diuretics, or vomiting for weight control?

Have you ever tried prescription medications for weight loss?

If yes, when was the last time?

Please check all that you have tried before:

Type your full name to electronically sign this paperwork:

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Notice of Privacy Practices:

Hayes Clinic 520 N Collegiate Drive Paris, TX 75460 License Number: H 9983 Effective Date: April 1, 2003

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Our office strives to protect your privacy in all phases of care we provide for you. Your records can only be released to another party if you have given our office written permission for us to do so. This protection covers the release of information to pharmacies, other doctors, and insurance companies. We must have your written permission on file before we can release your information. On file in our office, we have a complete copy of the NOTICE OF PRIVACY PRACTICES/HIPAA FORMS, and you are entitled to a copy of this notice upon request. Please contact our staff if you would like a copy. By signing below, you show that you have been advised of our privacy practices.

DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Smart Scale Results

Click or drag files to this area to upload. You can upload up to 2 files.

Please upload photo documentation or a screen shot of your Smart Scale weight reading that includes your weight, fat percentage, etc.

ID Upload (copy)

Click or drag a file to this area to upload.

Please upload a clear photo of your state issued ID or Driver’s License.

A smart scale is required for all initial TeleMed weight loss appointments.

I understand.

Most Recent Lab Work

Click or drag files to this area to upload. You can upload up to 3 files.

Please upload your lab work. Lab work should include: Lipid Panel, Thyroid Panel (Including Free T3), BMP (Basic Metabolic Panel)