VitalStats — Precision Wellness for Body & Skin

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This form is for patients seeking our Tirzepatide Weight Management Program only. For other inquiries, please visit our Contact page.

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Your information is treated as Protected Health Information (PHI) and handled with strict confidentiality — accessible only to our licensed clinical team, never shared with third parties.

First and Last Name *

Date of Birth *

Month

Day

Year

Gender *

FemaleMale

Phone Number

Email Address

Height *

feet

inches

Current Weight *

Waist Circumference (in cm) — Optional

Optional — measure around your belly button level.

Smoking / Vaping Status *

SmokerVaperNon-Smoker

Drinking Frequency *

NeverOccasionalMore than once a week

Do you or any family members have a history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Type 2 (MEN 2)? *

YesNo

Do you have a history of pancreatitis? *

YesNo

Do you have a history of gallbladder disease? (Gallstone, Cholecystectomy) *

YesNo

Do you have a history of severe gastrointestinal disease? *

YesNo

Do you have type 2 diabetes? *

YesNo

Are you currently pregnant, breastfeeding, or planning to become pregnant? *

YesNo

Please list any major surgeries you've had and their dates

Please list all current medications

Any known allergies

I acknowledge the importance of medical supervision during GLP-1 treatmentI understand this medication may have side effects such as nausea, constipation, or risk of thyroid tumorsI certify that the information provided above is accurate to the best of my knowledge

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Your information is treated as Protected Health Information (PHI) and handled with strict confidentiality — accessible only to our licensed clinical team, never shared with third parties.

What happens next

✓Our clinical team reviews your form within 24 hours
✓We will reach out via your provided contact info
✓A personalized program will be designed for you
✓All information is kept strictly confidential

⚠️ For medical emergencies, please contact your local healthcare provider or emergency services. VitalStats provides wellness consultations and is not a substitute for emergency medical care.

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Your Data is Protected

All information submitted through this form is treated as Protected Health Information (PHI) and handled with strict confidentiality. Your data is securely stored and accessible only to our licensed clinical team — never shared with third parties.

Start your wellness
journey today.

Medical History Form

Start your wellnessjourney today.

Medical History Form

Start your wellness
journey today.