Spa at West Ashley -Weight Loss Form

Have you ever been hospitalized, under medical care, or checked into rehab for alcohol or drug treatment?

Yes No
If yes, please explain:
Please list any and all medications you are currently taking, including dose and reasons for taking:
Weight Loss Health History Questionnaire

Please fill in the form below
Name:

First Name Middle Name Last Name
1. Do you have elevated cholesterol?

Yes No
2. If yes, when was your cholesterol level last checked?

Yes No
3. Do you or any family members have conditions with blood clots?

Yes No
4. Are you on birth control presently?

Yes No
5. Do you have an implantable birth control device?

Yes No
6. Is there any possible chance that you are pregnant?

Yes No
7. Is there any possible chance that you will become pregnant?

Yes No
8. Have you had an abnormal pap test in the past?

Yes No
9. Have you ever had a LOOP or LEEP procedure?

Yes No
10. Have you or a family member been diagnosed with cancer?

Yes No
11. Do you have high blood pressure that is not controlled?

Yes No
12. Have you ever taken nitrates for chest pain?

Yes No
On average, which of the following reflects your daily eating habits? (Please check all that apply)

3 meals with healthy snacks 3 meals 2 meals or less Graze: small, frequent meals Skip breakfast or other meals Generally eat on the run No regular eating pattern Often crave sweets / carbs
If grazing, how many meals per day?
Please select your current level of exercise:

None Light exercise: 1-3 times per week, easy pace, stretching, walking, etc. Moderate exercise: 2-3 times per week, moderate pace, some weights, etc. Heavy exercise: 3-4 times per week, vigorous pace, weights, fast running, etc.
Health Information

Past or Present Health Conditions
Breast Cysts or Tumors (Cancer):

Yes No
Diabetes:

Yes No
Hypoglycemia:

Yes No
Strokes:

Yes No
Heart Disease:

Yes No
High Blood Pressure:

Yes No
Uterine Fibroids (Cancer):

Yes No
Cancer (previous or current):

Yes No
Hormone Imbalance:

Yes No
Thyroid Imbalance:

Yes No
Anorexia:

Yes No
Bulimia:

Yes No
Drug Addiction:

Yes No
Are you allergic to sulfur, food, or medication?

Yes No
If you answered Yes, to any of the above, please explain:
Lifestyle Questionnaire

Health Risk Analysis
Today's Date:

Month Day Year
Birth Date:

Month Day Year
Age:
Height:
Weight:
Name

First Name Last Name
Gender:
Address:

Street Address

Street Address Line 2

City State

Zip Code
E-mail:
Cell Phone Number:

Area Code Phone Number
How did you hear about us:
If referred by someone, who?
Please answer the following questions honestly so we can do our best to help reach your goals.
What made you decide to do something about your weight today?
Who encouraged you to lose weight?
Can you commit to one visit a week?

Yes No
How many pounds would you like to lose?
How fast do you want to be slim, trim, & fit?
Have you ever attended any other weight reduction centers, if so, which ones?
What kind of diets have you tried on your own, and for how long?
Does your family support your weight loss efforts?

Yes No
Have you been advised by your family physician to lose weight?

Yes No
If yes, what is your doctor's name?
Do you eat because of emotions?

Yes No
If yes, please explain:
Signature

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Weight Loss Health History Questionnaire

Health Information

Lifestyle Questionnaire