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NEW Patient Intake Questionnaire
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First name
*
Last name
*
Birthday
*
Month
Day
Year
Address
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Phone
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Who can we thank for referring you to Garay Essentials? (if no one referred you, please type "N/A")
*
Social history - Tobacco/Nicotine Use
*
Current Smoker
Former Smoker
Daily Vape Use
Occasional Vape Use
Nicotine gum/lozenge/patch use
No Tobacco or nicotine use
Social History- Alcohol Use
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No alcohol use
Occasional/social drinker
Weekly alcohol use
Daily alcohol use
History of alcohol dependence
Social History- Recreational Drug Use
*
No recreational drug use
Occasional cannabis and/or THC use
Regular cannabis and/or THC use
Use of other recreational drugs
History of substance abuse
Social History- Caffeine Use
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No caffeine use
Occasional caffeine (1–2 times/week)
Daily caffeine (coffee, tea, energy drinks)
High caffeine use (multiple servings/day)
Do you have any known allergies?
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Select any medical conditions you currently have
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Diabetes
Hypertension (high blood pressure)
Ashtma
Thyroid disorder
None of the above
Other
Please list "other" below
Rate your current overall health from 1 to 10
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1
2
3
4
5
6
7
8
9
10
What is your height?
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What is your current/most recent weight?
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What health goals do you have? please include goal weight if that is something you are targeting.
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Have you had any surgeries in the past? Please list below as well as the year they were performed.
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List any medications you are currently taking, to include anything over the counter, herbals, or other
*
Do you have a personal or family history of medullary thyroid carcinoma?
*
Select any habits you currently have
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Following a special diet for weight loss (ex: keto, intermittent fasting, calorie counting)
Following a medically prescribed diet (ex: diabetic, cardiac, gluten-free)
Regular exercise (3+ times weekly)
Occasional exercise (1-2 times weekly)
History of weight loss surgery (gastric bypass, sleeve, etc.)
Current/Prior use of GLP-1 medications (Ozempic, Wegovy, Mounjaro, Zepbound, etc)
None of the above
Submit
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