Intake Form Ideal Metabolic Health
Name
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First Name
Last Name
Birth Date
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Month
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Day
Year
Date
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.
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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 is monitoring medications and any heath concerns that you list here (besides stress and weight issues). If you are on medications (particularly for high blood pressure or hypothyroidism), I will monitor those that may need changed as you lose weight, but you will need others to be monitored during and after the program as your need for them may change.
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I acknowledge
List any medical diagnoses you have:
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What medications, supplements and over the counter items do you take regularly or are currently prescribed:
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List past surgeries and hospitalizations
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List any allergies to medications
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Personal history
What are your main interests and hobbies?
What is your line of work or study
How many hours of screen time do you average per day?
Are you married or in a relationship?
Tobacco/Drug Use:
Specify current habits and frequency of use
Weight history
Current weight:
Current height:
BMI (if known):
Weight History:
Provide a brief overview of weight fluctuations, significant weight changes, or previous weight loss attempts.
Nutritional history
Typical Diet:
Describe daily eating habits, including meal patterns, food preferences, and any known dietary restrictions
Snacking Habits:
Detail frequency and types of snacks consumed
Beverage intake:
Specify daily water intake and consumption of other beverages, including caffeinated and sugary drinks and alcohol
Physical Activity
Current Daily Activity:
Describe what you do for the majority of the day (i.e. sit at a desk)
Current Exercise Routine:
Describe the type, frequency, and duration of physical activities
Exercise Preferences:
Describe any preferences or limitations regarding exercise
Psychosocial Factors:
Stress Levels:
Rate stress levels on a scale of 1-10, with 10 being the highest
Emotional well-being:
Briefly describe emotional health and any factors contributing to emotional eating
Support System:
Identify sources of support, including family, friends, or community resources
Does your mood affect your life or daily activities?
How do you manage stress?
Sleep:
Sleep patterns:
Describe sleep duration, quality, and any known sleep disturbances
Do you wake up feeling refreshed?
Does your energy level affect your daily activity?
Goals and Expectations:
Medical and weight loss goals
Short-Term Goals (3-6 months):
Define specific, measurable, and achievable short-term medical and/or weight loss goals
Long-Term Goals (Beyond 6 months):
Outline broader health and weight maintenance objectives
Current picture of your health
Health History
No, Never
Yes, currently
Not Currently,but within the last year
Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheaded
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Belching/gas
Constipation
Diarrhea
Daily bowel movements
Submit
Should be Empty: