SLIM TLC® New Patient Form

SLIM TLC® New Patient Form

For best care and outcomes, please complete as thoroughly and accurately as possible.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about SLIM TLC® (if word of mouth, please include name)?
Medical conditions (please include all)
Type "None" if applicable.
Medications (please include all prescription and over-the-counter meds)
Type "None" if applicable.
Current Weight
Height
BMI (calculated automatically)
Waist Circumference*
*Measured at the top of your lateral hip bones (iliac crests)
Ultimate Goal Weight
To calculate at what BMI a particular weight would be, visit https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm (highlight the link, right-click, and click "Go to https://www.nhlbi.nih...")
Short-Term Goal Weight
Please indicate:
*Dietary Preference:
How would you describe your eating habits?
How often do you eat out?
How many sugared beverages do you drink on average per day (including juice)?
How much alcohol do you usually drink (include what type and how often)?
About what percent of your diet consists of "whole" plants?*
*Whole means eaten whole or prepared healthily, i.e., without any sugar, oil (other than extra-virgin olive oil/EVOO), white flour, or fatty animal products, and not fried
How often do you consume fatty seafood per week or month, and what type?*
*Fatty seafood includes salmon, trout, tuna, herring, sardines, anchovies, and mackerel
Describe your level of physical activity and exercise type/frequency?
What are your hobbies and interests?
What is the most you have ever weighed?
What has contributed to most of your weight gain?
What is currently motivating you to lose weight, i.e., why is it important to you?
Describe any weight loss efforts you have made, or programs you have tried, in the past:
Medicine preference
If you take medicine, how long would you like to be on it?
*You have to decide how much of the work you want the medicine to do for you, and how much you want to do. The more you can adopt and implement the two foundational tools of SLIM TLC, the lower the dose of medicine you'll need to achieve your goals, and the easier it will be to wean off the medicine without regaining the weight.
Is there anything else you would like us to know about you?
To-Do Checklist (check each one)

I will do my very best to attend at least one SLIM TLC® individual OR group nutrition OR fitness coaching session (in-person OR virtual): Monthly for the first six months (6 total needed before being able to advance to Level 2, with associated price drop), and every 2 months for the next six months (3 needed to advance to Level 3) – then hold monthly calls with the Nutrition or Fitness Coach during the second year.
Regarding the SLIM TLC® Map:
Next task:

Book the initial appointment for 60 minutes
At my initial appointment (time-willing) I would like to (check all that apply):
Please let us know if you have any questions or concerns:
Please take your photo.
Signature
See you thin!
Should be Empty: