The Orlando Institute of Weight Management

Patient Demographics

Last Name *

MI *

First Name *

Age *

Date Of Birth *

Gender *

Male

Female

Street address *

City *

State *

Zip *

Country *

Cell phone *

Email address *

Occupation *

Employer *

Emergency contact and relationship to you *

How did you learn about The Orlando Institute of Weight Management? *

Patient Medical History

Name of medication, how do you take it and the disease it is treating *

Are you allergic to medications or foods? *

Family Medical History

(If a blood relative has suffered the following, please indicate relationship)

Obesity

Abnormal Lung Function

Obstructive Sleep Apnea

Fatty Liver Disease

Gall Bladder Disease

Abnormal Periods

Infertility

Polycystic Ovarian Syndrome

Arthritis

Gout

Intracranial Hypertension

Stroke

Cataracts

Glaucoma

Thyroid Disease

Heart Attack

PreDiabetes

Diabetes

High Cholesterol

High Blood Pressure

Other Diseases?

Hospitalizations, please list year and reason for admission

Food and Drink Diary

Please let us know what you typically eat and drink throughout the day.

Breakfast Foods *

Breakfast Drinks *

Snack Foods *

Snack Drinks *

Lunch Foods *

Lunch Drinks *

2nd Snack Foods *

2nd Snack Drinks *

Dinner Foods *

Dinner Drinks *

3rd Snack Foods *

Are you an emotional eater? *

Yes

Do you drink alcohol? *

Yes

How often?

Do you smoke or vape? *

Yes

How Many times per day?

What are some things that trigger your hunger? *

Are you the person responsible to cover the cost of the program if you decide to start? If no, who will be the person in charge?

You are one step away from having the health that you deserve!

Please watch this important video with the next steps instructions.

Choose the best way to fill your consultation form:

Note: Our free consultations are IN PERSON at our office.

If you would like to request a virtual consultation, please email us at: OrlandoWeightLossMD@gmail.com before you fill the consultation form.

Note: Our free consultations are IN PERSON at our office.

If you would like to request a virtual consultation, please email us at: OrlandoWeightLossMD@gmail.com before you fill the consultation form.

IMPORTANT: Dr. Green offers semaglutide & tirzepatide injections as part of your weight loss program.