Medical Weight Loss Program Intake Form

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Patient Name*

First MI Last

Date of Birth*

Age*

Sex*

Male

Female

Email*

Phone*

Address*

Street Address City State ZIP Code

Emergency Contact Name*

First Last

EC Relationship*

EC Phone*

Occupation*

How did you hear about us?*

Are you under the care of a qualified healthcare professional? Please list whom.*

As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues - that’s what we’re covering). If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change.

Patient Signature*

I acknowledge the above statement.

Date*

MEDICAL HISTORY

Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc.)*

What medications, supplements and over the counter items do you take regularly or are currently prescribed?*

Any past surgeries and hospitalizations?*

Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer.*

PERSONAL HISTORY

What are your main interests and hobbies?

What is your line of work or study?

Do you exercise regularly? Please detail.

What kind of other movement or activities do you enjoy?

Do you have problems falling or staying asleep?

How many hours do you sleep?

Do you wake up refreshed?

How is your energy?

Does your energy level affect your daily activities?

How would describe your mood, generally:

Does your mood affect your life or daily activities?

How would you describe your stress level?

What are your sources of stress?

How do you manage stress?

Do you have people close to you who support you?

DIET AND LIFESTYLE

Do you regularly drink alcoholic beverages? If yes, how many per week?

Do you smoke tobacco?

Do you use recreational drugs?

How is your appetite?

Snack Habits

What:

How much:

When:

Typical Breakfast

What:

How much:

When:

Typical Lunch

What:

How much:

When:

Typical Dinner

What:

How much:

When:

How often do you eat out?

What restaurants do you frequent?

How often do you eat “fast foods”?

Food allergies?

Food dislikes?

Food cravings?

Do you eat because of emotions (explain)?

Do you drink coffee or tea? If Yes, how much daily?

Do you drink pop / soft drinks? If Yes, how much?

Do you use sugar substitutes?

What are your worst food habits?

How much fluids do you normally drink? Please approximate in ounces.

Please list all types of beverages you regularly drink.

Please list any food allergies, intolerances, or foods you avoid and the reason.

What past struggles and difficulties have you experienced in terms of food and dieting?

What diet and exercise programs, protocols, plans or approaches have you tried in the past?

What types of diet and exercise approaches have worked for you in the past?

And what hasn't worked for you at all?

When did you first become overweight?

How did your weight gain start? Describe any circumstances.

What do you think is the cause of your weight problem?

What was your highest weight? (excluding pregnancy)

What was your lowest weight?

Have you ever stayed the same weight for 10 years or more?

How MOTIVATED are you to lose weight?

Is there anything else you would like to tell us?

Please list the factors you feel have contributed to your current weight (check all that apply)