Welcome to WellnessBLean Medical Weight Loss Program, where check-in is virtual or In-office. The program designed to guide and help achieve the results you desire. Fill out the form below to ensure you get the most accurate program built. Name * First Name Last Name Email * Phone (###) ### #### Please provide: D.O.B, Gender, Current Weight, Desired Weight. List any weight-loss diets or weight-loss medications you have been on during the past 12 months, along with the reason(s) for following it, the benefits or problems you experienced with it, and the reason(s) for stopping any diet or medication. * Have you ever been this weight before? List any weight-loss diets or weight-loss medications you have been on during the past 12 months, along with the reason(s) for following it, the benefits or problems you experienced with it, and the reason(s) for stopping any diet or medication. Do you see a primary care provider? How often? If any, list any current Medical Problems If any allergies, please list. Do you have any thyroid conditions? Yes No Do you have any heart conditions? Yes No Do you have Glaucoma? Yes No Are you taking any medications for mood? Anxiety? Depression? Please review all form fields above and ensure they are true to the best of your knowledge. The above information is true to the best of my knowledge. I agree * Agree Thank you! We will have one of our staff members reach out to you after your form has been reviewed.