Weight Loss Intake Weight Loss Intake Consultation History (Medical Weight Loss)Patient NameDate MM slash DD slash YYYY First NameLast NameEmail Address:City:State:Zip Code:Home Phone:Cell Phone:Date of Birth: MM slash DD slash YYYY Age:Height:Weight:Gender: Male Female How did you hear about us?:Who referred you?:How much weight do you want to lose?How fast do you want to lose it?What reasons/special occasions/ goal date do you have to lose weight?What options have you tried to lose the weight?In what ways do you suffer from being overweight?Do you have any body aches or pain (low back, legs/feet, neck, arms/hands)? Yes No If so where do you have pain?If shown a way to lose the weight quickly and efficiently, would you change your routines in order to accomplish your goal of weight loss? Yes No Would you commit to one visit a week?: Yes No Is there anything preventing you from starting immediately on your weight loss program?(Concerns: Time or Money) Yes No On average, which of the following reflects your daily eating habits? (Please check all that apply): 3 meals with snacking 3 meals 2 meals or less Skip breakfast or other meals Generally eat on the run No regular eating pattern Often crave carbs and sweets Graze; small frequent meals How many per day?Current level of exercise (Please check one): None Light exercise (1-3 times per week, easy, stretching, walking, etc.) Moderate exercise (2-3 times per week, moderate , light weights, etc.) Heavy exercise: (3-4 times per week, vigorous , heavy weights, running, etc.) Past or Present Health Conditions (Please check all that apply): Diabetes Strokes Heart Disease High Blood Pressure Thyroid Imbalance Anorexia Bulimia Drug Addiction Currently pregnant or nursing Allergic to sulfur, food or medication Please list current medications:What is most important to you in deciding to lose weight? (Please check all that apply): Effectiveness “My results are my top priority.” Time “I want results quickly.” Service “I need extra support along the way.” Ease “I have a difficult time losing weight.” I understand that my patient file will be kept completely confidential unless I give written permission for my information to be released.SignatureDate MM slash DD slash YYYY Notes:Not Approved if: Taking Nitrites for heart, Cancer, Severe Diabetes, Stroke history, Pulmonary Embolism Does the patient qualify: Yes No if yes, schedule 1st appointment and give consent to sign. PhoneThis field is for validation purposes and should be left unchanged.
