Dr. Collado's Weight Loss Program & Botox

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* Please type your name as it appears on your ID:

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* Date of Birth:

Date / Time

Date

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* What is your gender?

Female

Male

Other (specify)

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* Patient Information:

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* How did you hear about us?

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* Has a physician ever told you that you have any heart conditions?

Yes

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* Do you have a history of chest pain?

Yes

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* Do you have a history of dizziness?

Yes

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* Do you have a history of seizures?

Yes

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* Do you have a history of strokes?

Yes

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* Do you have a history of bone or joint problems?

Yes

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* Are you aware of any reasons why you cannot perform physical activity?

Yes

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* Are you pregnant or planning to get pregnant in the next 6 months?

Yes

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* Are you taking any psychiatric medications?

Yes

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

Yes

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

Yes

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* Are you allergic to any medications?

Yes

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

Yes

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* Do you have any reasons why you may be unable to lose weight?

Yes

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* Do you have problems controlling your weight?

Yes

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* 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

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* Do you exercise regularly?

Yes

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

Yes

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

Yes

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* 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:

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

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

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I Agree to the Patient Informed Consent.

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I Agree to the HIPPA Notice of Privacy Practices.

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

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

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* WEIGHT:

What is your current weight in pounds?

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

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* 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.

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?