Patient Record & Health Background Form
Please complete this form to help us understand your health background and current wellness needs. Your information allows us to provide a more accurate and personalized consultation.
Basic Information
Program Interest
Which program are you interested in?
Body & Health Basics
Timeline of Weight Concern / Symptoms
Goals
What are your wellness or weight-loss goals?
Previous Methods Tried
Methods you’ve tried before
Medical Background
Medical Conditions or Current Medications
History of Thyroid Cancer (Y/N)
Pregnant, planning, or breastfeeding (Y/N)
Allergies (optional)
Readiness
Are you willing to undergo follow-up monitoring?
Are you comfortable with small injections?
🔒 “Your information is private & will only be used for your assessment, consultation, & personalized wellness plan. We do not share your data with third parties.”
Science-backed guided by Health Coaches and Licensed Physicians — A Sexual Health and Lifestyle Medicine Specialists.
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🔒 HIRAYA Lifestyle Clinic provides inclusive, science-based, and judgment-free care. Your information is 100% confidential and used only to personalize your wellness journey.
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