Intake form - Your Infinity Health

Health and Wellness History

First Name *

Last Name *

Date Of Birth

Gender *

Feet/Inches *

Current Weight (in lbs) *

Email *

Phone Number *

State

3. Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?

Yes, I currently take or have recently (within the last 12 months) taken a GLP-1 medication for weight loss Yes, I currently take or have recently (within the last 12 months) taken another medication for weight loss No

Please list the name, dose, and frequency of your current or recent (within the last 12 months) weight loss medication(s).

What was your starting weight in pounds (lbs)?

What is your current weight in pounds (lbs)?

Do you agree to only obtain weight loss medication through this platform moving forward?

Yes No

When was your last dose of medication? This question is required before further medication can be prescribed.

Please upload a picture of your current GLP-1 medication pen or vial.

If your last dose of GLP-1 medication was greater than 4 weeks ago, we restart the dose at level 1 (the lowest dose) of medication. Are you willing to restart at level 1 (the lowest dose) of medication?

Yes No

Do you currently take any medications? If so, please include name, dose, and frequency of all your medications.

Yes No

List of medication

Are you currently taking, plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs? If so, please include date range, name, dose, and frequency.

Yes No

List of medication

Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?

Yes No

Please list all your prior bariatric (weight loss), abdominal, and pelvic surgeries. Please include date range and type of surgery

Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification? If so, please provide brief details.

Yes No

Details

Are you willing to

Reduce your caloric intake alongside medication, if clinically appropriate Increase your physical activity alongside medication, if clinically appropriate None of the above

How has your weight changed in the last 12 months?

What is your current or average blood pressure range?

<120/80 (Normal) 120-129/<80 (Elevated) 130-139/80-89 (High Stage 1) ≥140/90 (High Stage 2)

What is your current or average resting heart rate range?

<60 beats per minute (Slow) 60-100 beats per minute (Normal) 101-110 beats per minute (Slightly Fast) >110 beats per minute (Fast)

What is your goal weight or body mass index (BMI)? Please note that while this information is helpful, medical decisions will be made by the clinicians keeping clinical evidence and patient safety at the forefront

Do you have any allergies?

Yes No

List of allergies

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