Compass Fat Loss Patient Information Form Step 1 of 6 16% General InformationPatient's Full Legal Name* First Last Marital Status*-- Select --SingleMarriedDivorcedWidow/WidowerPatient Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Mobile Phone*Home Phone*Work PhoneGender*GenderMaleFemaleDate Of Birth* Date Format: MM slash DD slash YYYY Occupation*How did you hear about us?*-- Select One --Word of mouthReferred by CFL patientInternet/Social MediaRadio WTIC-AM News Talk 1080Radio WTIC-FM 96.5Radio WWYZ-FM Country 92.5Radio WUCS-FM 97.9Radio other / Not surePrimary Care Physician* Dr.Dr.Mr.Mrs.MissMs. Prefix First Last Primary Care Office Phone*Primary Care Office Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Lifestyle InformationWhat is your height?*What is your current weight?*How long have you been overweight?*What is your goal weight?*When was the last time you were at your goal weight?*What was the cause/reasons for your weight gain?*Have you tried to lose weight in the past?*YesNoHow have you tried to lose weight in the past?What are your top 2 reasons for losing weight?Has your doctor recommended you lose weight?*YesNoWhat is your exercise activity level?*SedentaryModerateVigorousHow many days per week?Please enter a number less than or equal to 7.Tobacco Use*NoneDailyWeeklyInfrequentQuitAlcohol UseNoneDailyWeeklyInfrequentQuitCaffeine UseNoneDailyWeeklyInfrequentQuit Patient Health HistoryAnemia*SelfFamilyBothN/AAngina*SelfFamilyBothN/AArthritis*SelfFamilyBothN/AAsthma*SelfFamilyBothN/AAtrial Fibrillation*SelfFamilyBothN/ABack Pain - Lower Back*SelfFamilyBothN/ABack Pain - Mid Back*SelfFamilyBothN/ABenign Prostatic Hypertrophy*SelfFamilyBothN/ABlood Clots*SelfFamilyBothN/ACancer - type*SelfFamilyBothN/ACOPD (Emphysema)*SelfFamilyBothN/ACrohn's Disease*SelfFamilyBothN/ADepression*SelfFamilyBothN/ADiabetes - Type 1*SelfFamilyBothN/ADiabetes - Type 2*SelfFamilyBothN/AEpilepsy*SelfFamilyBothN/AFatigue*SelfFamilyBothN/AGallbladder Disease*SelfFamilyBothN/AGERD (Reflux)*SelfFamilyBothN/AGout*SelfFamilyBothN/A Patient Heal History - ContinuedHeadaches*SelfFamilyBothN/AHigh Cholesterol*SelfFamilyBothN/AHUV*SelfFamilyBothN/AHypertension (High Blood Pressure)*SelfFamilyBothN/AHypoglycemia*SelfFamilyBothN/AIntestinal Problems*SelfFamilyBothN/AIrritable Bowel Disease*SelfFamilyBothN/ALiver Disease*SelfFamilyBothN/AMigraine Headaches*SelfFamilyBothN/AMyocardial Infarction*SelfFamilyBothN/ANeck Pain*SelfFamilyBothN/AOsteoarthrotis*SelfFamilyBothN/AOsteoporosis*SelfFamilyBothN/APoor Sleep*SelfFamilyBothN/ARenal Disease*SelfFamilyBothN/ASeizure Disorder*SelfFamilyBothN/AShortness of Breath*SelfFamilyBothN/AStroke*SelfFamilyBothN/AThyroid Disease*SelfFamilyBothN/A Additional Health InformationDo you have a pacemaker/defibrillator?*YesNoAre you currently taking prescription medication?*Yes I amI do not take any medicationsWhat medication(s) are you currently on?Are you currently taking nutritional supplements?*Yes I amI do not take any nutritional supplementsWhat nutritional supplement(s) are you currently taking?Do you suffer from any known allergies?*YesNoList your known allergiesOther illnesses otherwise not listed?Previous surgical history?*YesNoSurgical InformationOn a scale of 1 to 10, 1 being lowest, how motivated are you to lose this weight?*12345678910 Insurance InformationAre you insured?*YesNoInsurerSubscriber/Member #Group # (if Applicable)Insurance Provider Phone #Deductible Met?YesNoSupplemental InsurerSupplemental Insurance Subscriber #Supplemental Insurance Group #Supplemental Insurance Provider Phone #CommentsThis field is for validation purposes and should be left unchanged.
