Weight Loss Clinic Screening Questionnaire Template
A well-designed screening questionnaire helps weight loss clinics efficiently pre-qualify patients for medical weight management programs. This template combines BMI eligibility verification, comorbidity screening, medication history review, and readiness assessment in a single form. Use it as an initial screening tool before the full clinical intake. Ideal for practices offering GLP-1 weight loss programs (semaglutide, tirzepatide), phentermine, or comprehensive medical weight management. The questionnaire is designed to identify candidates who meet clinical criteria while filtering patients who may need additional evaluation before enrollment.
Form Preview
Section 1 of 6
Basic Information
Let's start with your basic information.
Section 2 of 6
BMI Pre-Screening
Your measurements help us determine program eligibility.
Current Weight (lbs) *
200
Height (ft/in) *
5'8"
Do you know your BMI? *
No, calculate for me
Section 3 of 6
Health Conditions
Check any conditions you currently have.
Do you have any of the following conditions?
Section 4 of 6
Previous Weight Loss History
Tell us about what you've tried before.
What weight loss methods have you tried?
If you've tried prescription weight loss medications, which ones and what was the result?
Medication name, duration, results, side effects
Section 5 of 6
Health Screening
A few important health questions.
Are any of the following true for you?
Section 6 of 6
Readiness & Interest
Help us understand what you're looking for.
Which program are you interested in? *
GLP-1 weight loss (semaglutide/tirzepatide)
How soon are you looking to start? *
Immediately
This program operates outside of insurance, giving you and your provider full control over your treatment plan. Are you comfortable with a direct-pay model?
This is a preview. Actual form will be customized with your practice branding.
Compliance & Regulatory Notes
Screening questionnaires should not be used as a substitute for a clinical evaluation. They are a pre-qualification tool. A licensed provider must evaluate the patient before prescribing any medication.
BMI eligibility for FDA-approved GLP-1 weight loss medications: BMI >= 30, or BMI >= 27 with at least one weight-related comorbidity.
Screening for eating disorder history is important. Patients with active anorexia or bulimia should be referred for specialized care before enrollment in a weight loss medication program.
Data collected through screening questionnaires is protected health information (PHI) under HIPAA, even if the patient is not yet a patient of record. Ensure secure collection and storage. See HHS HIPAA: https://www.hhs.gov/hipaa/index.html
Want This Form Automated?
Karpa Health turns static intake forms into a fully automated clinical workflow.
- Branded patient intake embedded on your website
- AI clinical review with contraindication screening
- One-click prescribing to compounding pharmacies
- Automated follow-up and refill management
- E-signatures, HIPAA compliance, and audit trail
Related Clinical Forms
GLP-1 Patient Intake Form
Download a free GLP-1 patient intake form template for your clinic. Covers medical history, contraindications, BMI screening, and medication reconciliation. Customizable for semaglutide and tirzepatide programs.
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View template →Med Spa Patient Intake Form
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View template →Sources & References
Frequently Asked Questions
What is the difference between a screening questionnaire and an intake form?
A screening questionnaire is a brief pre-qualification tool used to determine if a patient is a potential candidate for a program. The intake form is a comprehensive clinical document completed during enrollment that captures full medical history, medications, and detailed health information needed for prescribing.
Can a screening questionnaire be used for marketing / lead capture?
Yes, many clinics embed screening questionnaires on their website as a lead qualification tool. Patients self-screen, and the clinic follows up with qualified candidates. Just ensure you clearly disclose how the data will be used and comply with HIPAA for any health information collected.
Should the screening questionnaire include pricing?
Including a pricing question (as this template does) helps set cash-pay expectations early and reduces time spent on patients who cannot afford the program. You do not need to list specific prices in the form itself. Many practices also use separate payment authorization forms that patients complete before beginning treatment. Whether and when to discuss pricing is entirely your decision as a practice owner.