Welcome to SoWal Health & Wellness.
850-353-2743
info@sowalhealth.com
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Text Us: 850-420-7252
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Consult with Our Experts
Name
Street Address
Phone
Date of Birth
Email Address
Sex
Male
Female
Marital Status
Single
Married
Widowed
Separated
Divorced
Race
Primary Care Physician
Primary Care Phone Number
Emergency Contact
Emergency Contact Phone
Emergency Contact Relationship
Health & Wellness History
Do you have any dietary restrictions?
How often do you exercise?
What type of exercise?
Do you feel stressed?
Yes
No
Check all that apply to you:
Pregnant
Might be pregnant
Breast Feeding
Currently Undergoing Chemotherapy
What is your current weight?
When was the last time you were your ideal weight?
How much do you want to lose?
What are previous diets you have tried?
Do you binge eat?
Yes
No
Do you suffer from cravings?
Yes
No
Do you eat because of emotions?
Yes
No
Please list ALL medications & Doses
Drug Allergies
Do you have any thyroid conditions?
Yes
No
Do you have any known heart disease?
Yes
No
Are you diabetic?
Yes, Type 1 Diabetes
Yes, Type 2 Diabetes
No
Are you depressed?
Yes
No
Do you have kidney or liver issues?
Yes
No
Family or personal history of thyroid cancer/Medullary thyroid cancer?
Yes
No
Family or Personal History of Multiple Endocrine Neoplasia Type 2 (MEN2)?
Yes
No
Personal history of pancreatitis or at risk of pancreatitis?
Yes
No
Personal history of gastrointestinal disease or intestinal bowel obstruction?
Yes
No
Personal history of anaphylaxis, allergic reaction or angioedema to GLP-1 agonist medications?
Yes
No
Please list all surgeries and dates:
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