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Date of Birth:
Month
Day
Year
Sex:
Male
Female
Gender at Birth:
Male
Female
Race:

EXERCISE

What type of exercise do you typically do?
Please check all of these that apply to you:

Please answer the following questions honestly about yourself. This helps us to better help you reach your goals.

When was the last date (as close as you remember) that you were at your ideal weight?
Month
Day
Year
How long did you maintain the weight loss with previous diets?
Which of the following statements is the MOST important element in deciding to use our weight loss services?
Effectiveness: "My results are my top priority."
Time: "I want results quickly."
Service: "I need extra support along my weight loss journey."
Price: "I need my weight loss plan to be affordable."
Please select which of the following condition(s) you'd like help with or more information on:
Please select ALL medical conditions that you currently have or have had in the past:
If yes, please select how often.
Daily
Weekly
Socially

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

After submitting this form, you will be automatically redirected to another site to schedule your appointment with Gold Star Urgent Care.

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