NEW PATIENT WEIGHT LOSS INTAKE FORM

NEW PATIENT WEIGHT LOSS INTAKE FORM
BASIC PATIENT INFORMATION
Name*

First NameLast Name
Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Type of Business
Email*
example@example.com
Birth Date

MonthDayYear
Date
Sex

MaleFemale
Birth Gender

MaleFemale
Height
Weight
Race (ie. White, Asian, African American):
Hispanic or Latino

YesNo
Marital Status

SingleMarriedWidowedSeparatedDivorced
Occupation
How did you hear about us?
Primary Care Physician:
Phone
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
HEALTH AND WELLNESS HISTORY
Has your doctor advised you to lose weight?
Do you have any dietary restrictions?

YesNo
If so, Please explain
How often do you exercise? What type of exercise?
Do you feel stressed?

YesNo
How often do you exercise? What type of exercise?
Check ALL that apply to you

PregnantMight Be PregnantBreast FeedingCurrently Undergoing Chemotherapy
Please answer the following questions honestly so we can do our best to help you reach your goals.
What changed that caused the weight gain (if anything)?
What’s the main reason you are seeking treatment at this time?
What are your goals about weight control and management?
What do you consider to be your ideal weight?
When was the last time you were at your ideal weight?
How much weight do you want to lose?
How many times a year do you diet?
What is the hardest part about managing your weight?
What have you tried in the past that has failed?
Please list all previous programs that you have tried in order to lose weight. Indicate dates and length of and any current medications

Program

	Date	Medication	Dose/Freq.
Weight Watchers
Liquid Diets
Keto Diet
Diet Pills (Phen-Fen)
Nutrisystem/Jenny Craig
Surgery

Have you maintained weight loss for up to a year with any of these programs?

YesNo
What did NOT work for you about these programs?
What has been your lowest _________ and highest __________ weight as an adult?
What’s more important inches lost or pounds?

InchesPounds
What’s more important, fast or permanent?

FastPermanent
How fast do you want to be slim, trim and fit?

FastPermanent
What would stop you from a weight loss program?

Type a question

	Yes	No
Do you binge eat?
Do you suffer from uncontrollable cravings?
Do you feel that food controls you?
Do you eat because of your emotions?
Do you eat between meals?
Do you feel that your eating behaviors are normal?
Does your family support your weight loss efforts?
Can you remember being at your ideal weight?

Briefly describe your daily eating behaviors:
What do you remember most about being at your ideal weight?
Commitment to weight loss: (please rate): (low) 1 2 3 4 5 6 7 8 9 10 (high)
What is the most important element in deciding to use our services?(Select only ONE of the four answers):

EFFECTIVENESS: “My results are my top priority.”TIME: “I want results quickly.”SERVICE: “I need extra support along the way.”AFFORDABILITY: “I need this to be affordable.”
Check the following conditions you would like help with or more information on:

Weight LossHormone BalancingNeuropathyFatigueThyroidImmune BoostingJoint PainGeneral WellnessKnee ArthritisImmuneQuitting SmokingDiabetic Educ.Memory & MoodPain ReliefStress ReliefFitness
List ALL medications & supplements you take (prescription & over the counter)
Drug Name:
Dosage:
How long have you taken & for what conditions?
Please list all known DRUG and FOOD allergies:
Drug Name Food:
Reaction:
Check ALL medical conditions that you may have had or currently have now:

ADD/ADHDAlcoholismAllergyAlzheimer'sAnemiaAppendicitisAsthmaArthritisCancerCeliac DiseaseChronic FatigueMigraineDepressionDiabetesEczemaEmphysemaEpilepsy/seizuresFibromyalgiaGall BladderGoiterGoutHeart AttackHeart DiseaseVertigo/DizzinessHepatitisHigh Blood PressureHigh CholesterolHigh Blood SugarHIVIAIDSIrritable BowelKidney Infect./stonesLow Blood PressureLow Blood SugarLyme DiseaseLupusMiscarriageMultiple SclerosisParkinson'sPneumoniaRaynaud'sRheumatoid ArthritisRinging in earsSinus InfectionStrokeThyroid ProblemsUlcers
Other:
Please list all previous surgeries & dates:
Alcohol use?

YesNo
Amount: (Daily / Weekly / Socially)
Tobacco use?

YesNo
Amount: (Daily / Weekly / Socially)
Former Smoker PPD

YesNo
How many years?
AUTHORIZATION & NOTICE OF PRIVACY PRACTICES

I understand that my private healthcare information is protected under HIPPAA Privacy Regulations.
*May we leave a message for you on your answering device?

YesNo
I fully understand that my signature is consent and authorization to be examined by the Center for Wellbeing medical team.

YesNo
I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me.

YesNo
Patient Signature*

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Date*

MonthDayYear
Date
CANCELLATION AND NO-SHOW POLICY
We understand that situations arise in which you must cancel your scheduled appointment. It is therefore requested that if you must cancel your appointment you provide a 24 hour notice. Appointments which are cancelled within less than 24 hour notice may be subject to pay the full balance owed at the time of
cancellation. Cancellation and no show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment.
We understand that unavoidable circumstances may cause you to cancel with less than a 24-hour notice, fees may be waived upon management approval. Our practice firmly believes that good physician/patient relationships are based upon understanding and good communication. Questions about cancellation and no show fees can be directed with the provider at 321-333-4383.

Please sign that you have read, understand and agree to this cancellation and no-show policy.
Patient Name*

First NameLast Name
Patient Signature*

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Date*

MonthDayYear
Date
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NEW PATIENT WEIGHT LOSS INTAKE FORM

BASIC PATIENT INFORMATION

HEALTH AND WELLNESS HISTORY

AUTHORIZATION & NOTICE OF PRIVACY PRACTICES

CANCELLATION AND NO-SHOW POLICY