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HPI
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Fill out for First Visit Only
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Primary Care Provider (name/location)
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What brought you to Progress & what are your goals?
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Briefly describe how your weight has changed throughout your life
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Weight you feel best at
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What are any barriers to achieving your goals?
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What weight loss programs, medications, or supplements have you tried?
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What is your job and work schedule?
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Who lives with you?
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Medical History
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Other Medical History
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Surgical history
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Other Surgical History
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Family history (Grandparents, Parents, Siblings, Children)
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Other Family History
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Additional Questions (Female only)
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Have you ever struggled with
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Are you using any form of birth control (if so, what kind)?
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Do your eating habits change around your menstrual cycle?
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Nutrition
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What nutrition habit would you like to improve upon the most?
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Have you previously seen a registered dietitian?
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What do you typically eat for breakfast?
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Lunch
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Supper
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Snacks
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What do you drink throughout the day?
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Alcohol Use
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Extra Nutrition Notes
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Smoking History
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Do you use any products containing THC?
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Physical Activity
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Current exercise regimen
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What type of exercise do you enjoy?
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Barriers to exercise
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Sleep
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How would you describe your sleep
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Do you experience any of the following (Select all that apply)
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How many hours of sleep do you get at night on average?
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Have you been previously diagnosed with a sleep disorder?
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Do you current use a CPAP?
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Do you take anything to help you sleep?
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Mental Health
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How would you assess your current mental health?
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Does your mental health affect your eating habits?
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