770.649.0094
4343 Shallowford Rd #150, Marietta,GA 30062
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Weight Loss
Lean Body Program
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Thyroid-the master regulator
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GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Plus
Procedures
Xeomin Wrinkle relaxer
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
770.649.0094
4343 Shallowford Rd #150, Marietta,GA 30062
VIRTUAL CONSULT
TEXT US
Home Page
About Dr. Kelley
Weight Loss
Lean Body Program
Wellness
Bioidentical Hormones
Thyroid-the master regulator
Adrenal Health
IV Therapy
GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Plus
Procedures
Xeomin Wrinkle relaxer
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
Home Page
About Dr. Kelley
Weight Loss
Lean Body Program
Wellness
Bioidentical Hormones
Thyroid-the master regulator
Adrenal Health
IV Therapy
GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Plus
Procedures
Xeomin Wrinkle relaxer
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
weight loss history form
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weight loss history form
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Name
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First
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Date of Birth
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Phone number
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Can you text you?
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Email
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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?
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If yes, what are they?
Do you have any other allergies?
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Please list any surgeries you have has in the past:
Do you have any medical reasons for exercise limitations?
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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?
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Do you have a Primary Care doctor?
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Food Talk
Do you eat breakfast?
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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?
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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?
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