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PATIENT INFORMATION
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Name
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Name you Prefer to be called?
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Sex:
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Address:
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City:
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State:
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Zip Code:
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Home Phone:
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Cellphone:
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Birthdate:
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Age:
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Height:
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Email Address:
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Education:
• • •
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EMPLOYMENT INFORMATION
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Employer:
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Occupation:
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Workphone:
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Extension:
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How did you hear about us?
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IN CASE OF EMERGENCY
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Name:
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Relationship:
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Phone:
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Spouse Name:
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Phone:
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Sharing Medical Information:
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Primary Care Physician:
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Location:
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Phone:
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May we contact your primary care phyisican
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To discuss your treatment?
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MEDICAL HISTORY
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Are you in Good Health at the present time?
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Explain If NO
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Do you have any Medical Problems?
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If YES, please mention it:
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Been treated by a psychiatrist/psychologist?
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Please explain if YES:
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Any Surgeries?
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If YES, please explain:
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Date of Surgery:
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Type of Surgery:
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Any prescribed medications at the present time?
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If YES, please explain:
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Prescription Drug:
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Dosage:
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Are you taking any over-the-counter medications?
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If YES, please explain:
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Product:
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Dosage:
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Any Allergies to any Medications?
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If YES, please mention:
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History of Heart Attack/Chest Pain or Condition?
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History of Glaucoma?
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Gynecologic History:
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Birth Year:
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NUTRITION EVALUATION
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What is your desired weight? (lbs)
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In what time frame
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would you like to be at your desired weight?
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Most you have ever weighed? (Non-pregnant)
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At what age?
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Have you tried other diets before?
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If yes, please specify (list all):
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Food(s) you crave:
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Do you drink coffee or tea?
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If YES, how much daily?
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Do you drink soda?
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If YES, how much daily?
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Do you drink alcohol?
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Type of Drink:
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If Yes, Average drinks consumed per week:
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Do you smoke?
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Do you exercise daily?
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If Yes, type of exercise?
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WEIGHT LOSS PROGRAM CONSENT
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