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Deaconess weight loss solutions - medical history form for initial

Deaconess weight loss solutions - medical history form for initial 2026

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52 votes

The document is a Medical History Form for initial consultation at Deaconess Weight Loss Solutions. It requires patients to provide personal information, medical conditions, current medications, surgical history, social habits (such as smoking and alcohol use), and family health history. Completion of this form is mandatory for candidates seeking participation in the weight loss program.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information at the top of the form, including your name, date of birth, and age. This section is crucial for identifying you as a candidate.
Next, provide details about your primary physician and the reason for your most recent visit. This helps establish your medical background.
In the 'Medical Conditions' section, check only those conditions that apply to you. Be sure to include any allergies and reactions to medications.
List all current medications, including over-the-counter drugs and vitamins. Accurate medication history is vital for your treatment plan.
Answer the yes/no questions regarding various health conditions honestly. This information is essential for assessing your eligibility.
Complete the 'History of Surgeries and Hospitalizations' section by detailing any past surgeries or hospital stays.
Fill out the 'Social History' section regarding smoking, alcohol use, and drug history to provide a comprehensive view of your lifestyle.
Finally, review all entries for accuracy before signing and dating the form at the bottom.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (52 Votes)

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How to get approved for medical weight loss?

Acquiring Approval After we have gathered your weight history, test results, documentation of exercise programs and other records, we will analyze them and submit a letter of recommendation to your insurance carrier, requesting approval for coverage of the procedure.

How much is a form weight loss program?

If you do not have insurance or your insurance does not cover the Form Health program, we offer a self-pay plan for $299 per month that covers your Form clinician visits in addition to appointments with your Registered Dietitian, unlimited messaging and access to the Form platform.

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