Mastering your journey

Mastering your Wellness Journey

Your journey is UNIQUE to you, we are here every step of the way

STEP 1 – NEW PATIENT FORM

Begin your journey by filling out the NEW PATIENT form. If you prefer, you can complete this form at the clinic. During your visit, we will measure your blood pressure and weight to ensure a comprehensive assessment

STEP 2 – CONSULTATION WITH YOUR DOCTOR

Set aside approximately 20 minutes for an in-depth discussion with your doctor. This crucial step allows us to understand your unique needs and create a tailored plan for your success

STEP 3 – MEDICATION ORDER

Following your consultation, we will order your diet syrup medication for the upcoming month, ensuring you have the necessary support as you progress on your journey

STEP 4 – REACHING YOUR GOAL

Once you’ve achieved your target weight and are considering discontinuing your medication, please consult with us for guidance on yow to taper down effectively before stopping

STEP 5 – OPTIONAL

With or Without medication, join one of our iTHRIVE programs. To enhance your lifestyle habits and fuel your understanding of food psychology, consider joining our iTHRIVE program. This comprehensive initiative offers valuable resources and strategies to support your long-term success

We are committed to walking alongside you every step of the way as you MASTER YOUR WELLNESS JOURNEY!

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Patient Surname / Pasient Van *

Patient Name / Pasient Naam *

Patient Contact Number (Work) / Werks telefoon nommer

Patient Contact Number (Home) / Huis foon nommer

Patient Contact Number (Mobile) / Selfoon Nommer *

Patient E-mail Address / Pasient E-pos Adres *

Patient ID Number / Pasient ID Nommer *

Patient Address / Pasient Adres *

Please complete your address, including your town and code

Patient Occupation / Pasient Beroep *

Patient Allergies / Pasient Allergie *

Patient Medication / Pasient Medikasie *

Please list all the medication that you are currently taking daily / Lys asb alle medikasie wat u tans gebruik daagliks

Patient Height / Pasient Lengte *

Patient Weight / Pasient Gewig *

Patient Goal Weight / Pasient Doel Gewig *

Patient Blood Pressure / Pasient Bloed Druk

Will be taken at the clinic / Sal by die kliniek geneem word

Date / Datum *

Bottles / Bottels

At Clinic / By Kliniek

Do you exercise regularly / Oefen u gereeld? *

• Yes / Ja
• No / Nee

Are you a rehabilitated alcoholic / Is u 'n gerehabiliteerde alkoholis? *

• Yes / Ja
• No / Nee

Do you have high cholesterol / Het u verhoogte cholesterol? *

• Yes / Ja
• No / Nee

Do you suffer from Thyroid issues / Lei u aan Skildklier probleme? *

• Yes / Ja
• No / Nee

Do you suffer from Diabetes / Lei u aan Diabetes (Suikersiekte)? *

• Yes / Ja
• No / Nee

Do you have hypertension / Lei u aan verhoogte bloed druk? *

• Yes / Ja
• No / Nee

u Bloed /

Do you/did you suffer from depression / Het u tans of voorheen aan depressie gelei? *

• Yes / Ja
• No / Nee

Do you Smoke / Rook u? *

• Yes / Ja
• No / Nee

Do you breastfeed / Borsvoed u? *

• Yes / Ja
• No / Nee

Submit