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Client Information
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Name
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Email
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Phone
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DOB
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Address
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City/State/Zip
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Emergency Contact Name
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Emergency Contact Phone
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Referred by:
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Health Information
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Are you taking any medication? If yes, please list.
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Medications
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Do you have any Allergies?
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List allergies. (Medications, food, oils, lotion, etc)
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Are you pregnant? Females only.
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How many weeks?
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Have you had any recent injuries or receiving any medical interventions?
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List any injuries/interventions.
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Do you have any of the medical conditions listed below? If yes, please select them.
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Areas of swelling
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Autoimmune disorder
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Back/neck problems
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Bleeding disorder (blood thinners, hemophilia)
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Blood clots
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Bruise easily
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Bursitis
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Cancer
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Contagious condition (Covid, Flu, HSV, Shingles, etc)
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Diabetes
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Fibromyalgia
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Headaches
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Heart attack
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Heart failure
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Heart valve problem
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Hypertension
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Kidney disease
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Multiple sclerosis
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Neurological condition (i.e. Guillain-Barre Syndrome, myasthenia gravis, etc)
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Neuropathy
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Osteoarthritis
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Osteoporosis
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Phlebitis
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Sciatica
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Seizures
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Stroke
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Tendinitis
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TMJ (temporal mandibular joint disorder)
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Varicose veins
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Vertigo
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Weight Management Information
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What is your main reason for weight management treatment? Select all that apply?
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Elaborate on other reasons.
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What else motivates you for weight management treatment? Select all that apply.
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What treatments are you interested in? Select one.
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Have you taken any of the following medications for weight loss? Select all that apply.
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List side effects if any.
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Have you previously tried any other weight loss program?
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What were the results of your previous weight loss program?
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What was your lowest adult weight in pounds?
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What is/was your highest adult weight in pounds?
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Do you exercise regularly?
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What is your activity level at work? Select one.
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Please list foods that you eat frequently?
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Do you tend to eat more when stressed?
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What do you feel your stress level is on a scale from 1 to 10?
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What is the main source of your stress?
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Acknowledge and Release
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