Intake Weightloss – Northwestern Access

Step 1 of 19

This field is hidden when viewing the form

Status

New

On hold

Complete

This field is hidden when viewing the form

Provider ID (Hidden)

Clinical History

This clinical history takes 5-7 minutes to complete, you can save in case you need to pause.

What is your gender?(Required)

Male

Female

What's your date of birth?(Required)

MM slash DD slash YYYY

Are you at least 18 years old and live in Illinois?(Required)

Yes

We're Sorry

State laws require you to be at least 18 years old and live in Illinois to receive our services.

What is your current weight in pounds?(Required)

What is your height?

Feet(Required)

Inches(Required)

This field is hidden when viewing the form

Total height in inches(Required)

This field is hidden when viewing the form

BMI(Required)

Have you ever had any of the following conditions?(Required)

Our medications may impact these conditions so it is important that we know.

Pancreatitis or pancreas disease

Gallstones or other gallbladder disease

Liver disease

Kidney disease

Diabetes

Eating disorder

Suicidal ideation or behavior

Alcohol misuse or abuse

Retinopathy (Eye disease)

None of the above

We're Sorry

Based upon your answer, we are unable to treat you without further evaluation. This does not mean you may not be a candidate. We recommend that you schedule a in-person or virtual consultation with Dr. Vinay.

Do you have a personal or family history of medullary thyroid cancer?(Required)

Yes

We're Sorry

Based upon your answer, we are unable to treat you. We recommend that you ask your primary care physician.

Do you have a personal or family history of Multiple Endocrine Neoplasia type 2 (MEN2)(Required)

Yes

We're Sorry

Based upon your answer, we are unable to treat you. We recommend that you ask your primary care physician.

Are you taking any of the following medications?(Required)

Select all that apply

Insulin

Metformin

Sulfonylureas such as glipizide (Glucotrol) or glimepiride (Amaryllis)

Megalitinides such as repaglinide or nateglinid

Directics such as furosemide (Lasix), bumetanide (Bumex) or Hydrochlorothiazide (HCTZ)

Bexarotene

Gatifloxicn

None of the above

We're Sorry

Based upon your answer, we are unable to treat you. We recommend that you ask your primary care physician.

Do you have any of the following apply to you?

I have been diagnosed with one or more health conditions(Required)

I have been diagnosed with one or more health conditions

Yes

Please list your health conditions

I have had one or more surgeries(Required)

I have had one or more surgeries

Yes

Please list your past surgeries

I am taking one or more medications(Required)

I am taking one or more medications

Yes

Please list your medications

I am allergic to one or more medications(Required)

I am allergic to one or more medications

Yes

Please list your allergies

Do you have plans to start or grow your family within the next 6 months?(Required)

This includes you or your partner becoming pregnant, undergoing fertility treatments, or undergoing IVF.

Yes

We're Sorry

Based upon your answer, we are unable to treat you. We recommend that you ask your primary care physician.

Great News. Seems Like You're Eligible

After you select your treatment, Dr. Vinay will confirm your a candidate. If he feels otherwise, you will receive a full refund.

Comments

This field is for validation purposes and should be left unchanged.