770.649.0094

4343 Shallowford Rd #150, Marietta,GA 30062

VIRTUAL CONSULT

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Home Page
About Dr. Kelley
Weight Loss
- Weight Management program GLP1
- Lean Body Program
Wellness
Oshot l Feminine Rejuv
Procedures
Testimonials
Pricing

770.649.0094

4343 Shallowford Rd #150, Marietta,GA 30062

VIRTUAL CONSULT

TEXT US

Home Page
About Dr. Kelley
Weight Loss
- Weight Management program GLP1
- Lean Body Program
Wellness
Oshot l Feminine Rejuv
Procedures
Testimonials
Pricing

Home Page
About Dr. Kelley
Weight Loss
- Weight Management program GLP1
- Lean Body Program
Wellness
Oshot l Feminine Rejuv
Procedures
Testimonials
Pricing

Weight Loss History

Home>Weight Loss History

General Information

Name:
Date of Birth:
Phone number
Email
Can we text you?
YesNo
What is your height and weight?
List all your medications
List all your supplements
Please list any medical problems you may have, for example, diabetes or hypertension
Do you have any allergies to medications?
YesNo
If yes, what are they?
Do you have any other allergies?
YesNo
Please list any surgeries you have had in the past
Do you have any medical reasons for exercise limitations?
If yes, what are they?
How long have you struggled with your weight? *
What is your overall goal for weight loss?
Please list anything you have tried for weight loss in the past.
How many times a week do you exercise?
What type of exercise?
Do you have a Primary Care doctor? *

Do you eat breakfast? Are you hungry in the morning?
YesNo
If you eat breakfast, what is a typical breakfast for you?
If you eat lunch, what is a typical lunch for you?
What is a typical dinner for you?
What has made it difficult for you to lose weight in the past?
Do you feel that you are an emotional eater?
YesNo
If you have food cravings, please list them here.
Have you had lab testing in the past 6 months?
YesNo

Name *

First

Last

Date of Birth *

Phone number *

Can you text you? *

Yes
No

Email *

What is your height and weight? *

List all your medications and dosages: *

List all your supplements and how you take them: *

Please list any medical problems you may have. For example, diabetes or hypertension: *

Do you have any allergies to medications? *

Yes
No

If yes, what are they?

Do you have any other allergies? *

Yes
No

Please list any surgeries you have has in the past: *

Do you have any medical reasons for exercise limitations? *

Yes
No

If so, what are they?

How long have your struggled with your weight? *

What is your overall goal for weight loss? *

Please list anything you have tried for weight loss in the past? *

How many times a week do you exercise? *

What type of exercise? *

Do you have a Primary Care doctor? *

Yes
No

Food Talk

Do you eat breakfast? *

Yes
No

If so, what is your typical breakfast?

What is your typical lunch? *

What is your typical dinner? *

Are you doing a lot of snacking after dinner? *

Yes
No

If so, what do you snack on?

What has made it difficult for you to lose weight in the past? *

Do you crave certain foods? *

Yes
No

If so, what foods do you crave?

Do you feel like you are an emotional eater? *

Yes
No

When is the last time you had lab testing? *

Are you willing to do a detox to start from a clean slate? *

Yes
No

Do you have activities you engage in to relieve stress? *

Yes
No

If you have a stress reliever, what is it?

Have you answered all questions truthfully and to the best of your knowledge? *

Yes

Phone

Ask Dr. K Questions

Name: *

Phone number *

Can we reach out to you by text? *

Yes
No

Email *

What do you want to learn more about from our medical side? *

Sex hormone balancing
Thyroid balancing
Weight loss-Body Composition Program
Skin Tightening
O shot
Wellness Therapies
Hair loss treatments
None

Is there a specific cosmetic procedure you want to learn more about? *

Microneedling
Nutritional IV therapy
Exilis skin tightening
Weight Loss-Body Composition
Wrinkle relaxers-Botox/Xeomin
Sculptra for Volume
Wrinkle fillers
O shot
PRP hair
None

What would you like to set up? *

Virtual Consult
Wellness Appointment
Aesthetic Appointment
Other

Custom Captcha *

=

Name

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Dr. Kelley and her staff customize a program for you to feel and look vibrant at any age.

Our practice focuses on Regenerative medicine and Regenerative Aesthetics.

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Pricing
Lean Body Program
Exilis Skin Tightening
Microneedling for beautiful and healthy skin
Sculptra
PRP Injections
PRP Hair Therapy
O Shot