Evaluation Form2 | hcgprotocol.com.au

Thank you for choosing HCG PROTOCOL to assist with reaching your fat loss goals. This form is to be completed by all new patients before your first consultation. It is important that you review and complete this information before your initial visit so we can be better prepared to start your lab work, exam and Stage 1 of your HCG Protocol Weight loss program. This will allow us to make better use of the time when we get together.

It is essential that this information is filled out completely. We will be reviewing all the information to create a personalised file for you, so please answer all questions honestly and to the best of your abilities. Please feel free to add any additional information to your responses that you feel will be beneficial for your first visit.

Full Name *

Email Address *

Phone *

Date *

Age: *

Address *

Suburb *

State *

Postcode *

Skype address

Do you require a consultant to contact you to book a consultation? *

Yes

No, I already have a booking

Please confirm the date of your appointment

Please confirm the time of your appointment

If your product is to be delivered, is the above address the same as the delivery address? *

Yes

No

(NOTE: Due to the nature of the product, someone must be able to be attendance at the given address to receive the package on the day of delivery)

DELIVERY ADDRESS *

Please add delivery address (where someone will be in attendance to accept on day of delivery):

Suburb *

State *

Postcode *

How did you hear about us?

Practitioner Referrer

MEDICAL STATUS

Current Weight *

Height *

General Health *

Excellent

Good

Fair

Poor

Which best describes you?

WEIGHT LOSS GOAL

How many Kgs/lbs do you wish to lose? *

Why do you feel you have gained weight, or have problems losing weight? *

SURGERIES

Surgery Name & Date

MEDICAL CONDITIONS/DISEASES

Please check all that apply to you

Please provide more details for any of the above you have indicated apply to you:

Diabetes on Medication *

Yes

No

Please provide more details

Clotting Issues / Increased Clotting Issues e.g. DVT or Pulmonary Embolism (PE): *

Yes

No

Please provide more details

Breast Cancer *

Yes

No

Please provide more details

Immunosuppression Therapy/Chemotherapy/HIV *

Yes

No

Please provide more details

Please provide details of any other medical conditions

CURRENT MEDICATIONS

Please provide details of any medications and dosage (in none, please state N/A) *

ALLERGIES

Any Known Allergies?

Yes

No

If Yes, List and describe reaction

FAMILY HISTORY

Please check all that apply to you

More Information

Dietary Restrictions

Do you have any Dietary Restrictions? *

Yes

No

Please specify Dietary Restrictions.

Previous HCG use

Have you tried other diets? *

Yes

No

Provide brief details.

Have you ever used HCG for fat loss? *

Yes

No

What method?

Injection

Spray

Drops

What kind, homeopathic or prescription?

Date/s undertaken

Duration (days)

Fat loss (kg)

Centimetres (if known)

Please include any other information not listed, but you feel may be relevant:

We are glad that you have taken this time to focus on yourself. We share in
your excitement to begin this vital step towards your weight loss goals and look forward to sharing in your journey and excitement with the results.

By typing your FULL NAME and TODAY’S DATE and then clicking on the COMPLETE button below, you acknowledge that you have read and agree to our conditions and that the information you have provided is true and correct to the best of your knowledge.

AGREEMENT

Do you agree with the above conditions? *

Yes

Patient Full Name *

Date *

PRINT FORM

If you have had blood tests taken in the last 6 months, please upload a copy here:

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Confidential Self Evaluation & Informed Consent Form

Welcome to the hCG Protocol for Weight Loss

MEDICAL STATUS

WEIGHT LOSS GOAL

ALLERGIES

Dietary Restrictions

Previous HCG use

AGREEMENT