Medical History Form

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Name *

First

Last

Phone Number *

Email *

Age *

Height *

Weight *

DOB *

Have you ever been seen by Dr. Loftus *

Smoker? How many packs per day? *

Prescription Medications *

Supplements *

Aspirin/NSAIDS *

Allergies to any medications *

Please check all that apply *

Other medical problems not listed above *

List ALL past surgeries *

you information ever

Interested in GLP-1? *

Enter full name to certify that the above information is complete and accurate *

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