Name *
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Age *
Height *
Weight *
DOB *
Have you ever been seen by Dr. Loftus * Select ChoiceYesNo
Smoker? How many packs per day? *
Prescription Medications *
Supplements *
Aspirin/NSAIDS *
Allergies to any medications *
Heart palpitationsHeart valve problemsHeart attackHigh blood pressureDiabetesAsthma/EmphysemaShortness of breathShingles
HepatitisBlood clotsBleeding tendenciesAuto immune disorderIntestinal problemsThyroid problemsArthritisN/A
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List ALL past surgeries *
Interested in GLP-1? * YesNo
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