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Which treatment are you interested in today?
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Marital Status
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Occupation
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Primary Care Physician (PCP) Name
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Preferred Pharmacy and Location
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How did you hear about Carma?
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Why do you want to lose weight?
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Were you overweight as a child
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Is this the heaviest you've ever been?
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How often do you think about losing weight?
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What diets or methods have you tried?
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I snack 2 or More times a day
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I rarely Plan Meals
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I skip 1 or More Meals a day
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Reasons to skip meals or overeat
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How often do you dine out?
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You feel your appetite is
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How do you feel when you eat?
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After eating you feel
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How often do you exercise?
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Has a Provider Recommended that you lose weight ?
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Are you ready to commit to losing weight?
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Female (only) answer following:
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Are you trying for pregnancy or planning pregnancy in the near future?
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Are you or could you be pregnant?
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Are you breastfeeding?
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Are you on any type of hormone replacement therapy?
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Are you on any contraceptive methods?
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Number of live births
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Past or current medical history
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Check all that apply
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Family Medical History
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Check all that apply
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List any medications currently taking
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List any vitamins you are currently taking
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Any hospitalization within the last 5 years?
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If hospitalization, provide date and reason
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Are you on any blood thinners?
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Do you or have you ever smoked?
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What is your weekly alcohol intake?
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Final Consent
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