Weight Loss Patient In Take Form

Name

Address

Include City, State and Zip Code

Phone

Birthday

Month

Day

Year

Age

Sex

Female

Male

Occupation

In case of Emergency:

Name

In Case of Emergency provide the name of your emergency contact.

Phone

In Case of Emergency provide the phone number of your emergency contact.

Relationship

In Case of Emergency provide the relationship of your emergency contact.

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.

I acknowledge the above statement above.

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Add your signature below as acknowledgement.

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 or hospitalizations?

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

Personal History

What is your line of work or study?

Do you exercise regularly? Please detail.

How is your energy?

How would you describe your stress level?

Diet and Lifestyle

Do you regularly drink alcoholic beverages?

Yes

If yes, how many per week?

Do you smoke tobacco?

Yes

What was your lowest weight?

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