Dr. Collado's Weight Loss Program & Botox

Question Title

Please type your name as it appears on your ID: (Required.)

Question Title

Date of Birth: (Required.)

Date / Time

Date

Question Title

What is your gender? (Required.)

Female

Male

Other (specify)

Question Title

Patient Information: (Required.)

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

How did you hear about us? (Required.)

Question Title

Has a physician ever told you that you have any heart conditions? (Required.)

Yes

Question Title

Do you have a history of chest pain? (Required.)

Yes

Question Title

Do you have a history of dizziness? (Required.)

Yes

Question Title

Do you have a history of seizures? (Required.)

Yes

Question Title

Do you have a history of strokes? (Required.)

Yes

Question Title

Do you have a history of bone or joint problems? (Required.)

Yes

Question Title

Are you aware of any reasons why you cannot perform physical activity? (Required.)

Yes

Question Title

Are you pregnant or planning to get pregnant in the next 6 months? (Required.)

Yes

Question Title

Are you taking any psychiatric medications? (Required.)

Yes

Question Title

Are you currently prescribed any medications that could be used to treat ADHD, ADD, or narcolepsy? (Required.)

Yes

Question Title

Are you prescribed any weight loss medications or stimulants (prescribed or over the counter)? (Required.)

Yes

Question Title

Are you allergic to any medications? (Required.)

Yes

Question Title

Have you ever been charged with any illegal activities relating to substance abuse or alcohol? (Required.)

Yes

Question Title

Do you have any reasons why you may be unable to lose weight? (Required.)

Yes

Question Title

Do you have problems controlling your weight? (Required.)

Yes

Question Title

Do you smoke tobacco products, use vape products, or exposed to second hand smoking? (This does not prevent someone from starting the program)

Smoke Tobacco Products

Smoke Using Vape Products

Exposed to Second Hand Smoking

None of the above

Question Title

Do you exercise regularly? (Required.)

Yes

Question Title

Do you have depression, anxiety, and/or increased stress due to your weight? (Required.)

Yes

Question Title

(Females) Do you have a history of eclampsia, preeclampsia, gestational diabetes, or gestational hypertension?

Yes

Question Title

Do you have any family history of heart disease, high blood pressure, diabetes, stroke, heart attack, and/or high cholesterol? If so, please list below:

Question Title

If you are currently taking any prescription medication(s), please list them (prescribed or over the counter). If none, please write "none": (Required.)

Question Title

Please use the space below to provide any additional information if you chose YES to any of the above:

Question Title

(Required.)

I Agree to the Patient Informed Consent.

Question Title

(Required.)

I Agree to the HIPPA Notice of Privacy Practices.

Question Title

(Required.)

I Agree to the Patient's Rights, Responsibilities, & Consent.

Question Title

How tall are you? You can provide feet and inches, or your height in inches. (Required.)

Question Title

WEIGHT: (Required.)

What is your current weight in pounds?

If wanting to start in-office, would you rather use our scale?

Question Title

Our program's main purpose is to prevent heart disease & encourage our patients to stay aware of their vitals. Blood pressure often goes unmonitored, and if high, can lead to coronary artery disease. (Required.)

What was your blood pressure recently? (Systolic / Diastolic)

What was your heart rate (pulse) after sitting for a few minutes?

If wanting to start in-office, would you like us to take your blood pressure for you?

Dr. Collado's Weight Loss Program & Botox

Question Title

* Please type your name as it appears on your ID: (Required.)

Question Title

* Date of Birth: (Required.)

Question Title

* What is your gender? (Required.)

Question Title

* Patient Information: (Required.)

Question Title

* How did you hear about us? (Required.)

Question Title

* Has a physician ever told you that you have any heart conditions? (Required.)

Question Title

* Do you have a history of chest pain? (Required.)

Question Title

* Do you have a history of dizziness? (Required.)

Question Title

* Do you have a history of seizures? (Required.)

Question Title

* Do you have a history of strokes? (Required.)

Question Title

* Do you have a history of bone or joint problems? (Required.)

Question Title

* Are you aware of any reasons why you cannot perform physical activity? (Required.)

Question Title

* Are you pregnant or planning to get pregnant in the next 6 months? (Required.)

Question Title

* Are you taking any psychiatric medications? (Required.)

Question Title

* Are you currently prescribed any medications that could be used to treat ADHD, ADD, or narcolepsy? (Required.)

Question Title

* Are you prescribed any weight loss medications or stimulants (prescribed or over the counter)? (Required.)

Question Title

* Are you allergic to any medications? (Required.)

Question Title

* Have you ever been charged with any illegal activities relating to substance abuse or alcohol? (Required.)

Question Title

* Do you have any reasons why you may be unable to lose weight? (Required.)

Question Title

* Do you have problems controlling your weight? (Required.)

Question Title

* Do you smoke tobacco products, use vape products, or exposed to second hand smoking? (This does not prevent someone from starting the program)

Question Title

* Do you exercise regularly? (Required.)

Question Title

* Do you have depression, anxiety, and/or increased stress due to your weight? (Required.)

Question Title

* (Females) Do you have a history of eclampsia, preeclampsia, gestational diabetes, or gestational hypertension?

Question Title

* Do you have any family history of heart disease, high blood pressure, diabetes, stroke, heart attack, and/or high cholesterol? If so, please list below:

Question Title

* If you are currently taking any prescription medication(s), please list them (prescribed or over the counter). If none, please write "none": (Required.)

Question Title

* Please use the space below to provide any additional information if you chose YES to any of the above:

Question Title

* (Required.)

Question Title

* (Required.)

Question Title

* (Required.)

Question Title

* How tall are you? You can provide feet and inches, or your height in inches. (Required.)

Question Title

* WEIGHT: (Required.)

Question Title

* Our program's main purpose is to prevent heart disease & encourage our patients to stay aware of their vitals. Blood pressure often goes unmonitored, and if high, can lead to coronary artery disease. (Required.)

Please type your name as it appears on your ID: (Required.)

Date of Birth: (Required.)

What is your gender? (Required.)

Patient Information: (Required.)

How did you hear about us? (Required.)

Has a physician ever told you that you have any heart conditions? (Required.)

Do you have a history of chest pain? (Required.)

Do you have a history of dizziness? (Required.)

Do you have a history of seizures? (Required.)

Do you have a history of strokes? (Required.)

Do you have a history of bone or joint problems? (Required.)

Are you aware of any reasons why you cannot perform physical activity? (Required.)

Are you pregnant or planning to get pregnant in the next 6 months? (Required.)

Are you taking any psychiatric medications? (Required.)

Are you currently prescribed any medications that could be used to treat ADHD, ADD, or narcolepsy? (Required.)

Are you prescribed any weight loss medications or stimulants (prescribed or over the counter)? (Required.)

Are you allergic to any medications? (Required.)

Have you ever been charged with any illegal activities relating to substance abuse or alcohol? (Required.)

Do you have any reasons why you may be unable to lose weight? (Required.)

Do you have problems controlling your weight? (Required.)

Do you smoke tobacco products, use vape products, or exposed to second hand smoking? (This does not prevent someone from starting the program)

Do you exercise regularly? (Required.)

Do you have depression, anxiety, and/or increased stress due to your weight? (Required.)

(Females) Do you have a history of eclampsia, preeclampsia, gestational diabetes, or gestational hypertension?

Do you have any family history of heart disease, high blood pressure, diabetes, stroke, heart attack, and/or high cholesterol? If so, please list below:

If you are currently taking any prescription medication(s), please list them (prescribed or over the counter). If none, please write "none": (Required.)

Please use the space below to provide any additional information if you chose YES to any of the above:

(Required.)

(Required.)

(Required.)

How tall are you? You can provide feet and inches, or your height in inches. (Required.)

WEIGHT: (Required.)

Our program's main purpose is to prevent heart disease & encourage our patients to stay aware of their vitals. Blood pressure often goes unmonitored, and if high, can lead to coronary artery disease. (Required.)