Bellezza Wellness Club Intake Form

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Email *

First name *

Date of Birth *

YYYY

Last Name *

Email *

Phone Number *

List Active Medical Conditions *

List Past Medical Conditions *

Weight at the start of the program *

Current Weight *

Fitness Goals *

List current medications, vitamins, dietary supplements and topical creams you are currently taking/using. *

List medication allergies *

Do you have or have you ever been diagnosed with the following hormone, liver or kidney conditions? *

Chronic kidney disease stage 3 or greater

Fatty liver disease

Kidney stones

Hypothyroidism/Hyperthyroidism

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

None of the above

Liver cirrhosis

Required

Do you have a personal or family history of MEN Type 2 Syndrome? *

Yes

Do not know

Do you have a personal or family history of Medullary Thyroid Cancer? *

Yes

Do not know

Are you pregnant or do you plan on becoming pregnant in the next 3 months? *

Yes

Maybe

Do you have a history of prior surgeries? *

Yes

Do you have any allergy to GLP-1 agonist medications?

Yes

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