Patient Intake Form MEDICAL WEIGHT LOSS BOTTUMZUP

Medical Weight Loss Program Intake Form

If questions below do not pertain please write NA

Patient Name: (Last) (First) (MI)*

Address*

Patient Address

Street Address Line 2

CityState

Zip

Phone number*

Email*

example@example.com

Birthdate

Date

Age

Gender

Occupation*

Were you referred by someone? If so, please provide their name below:*

Are you under the care of a qualified healthcare professional? Please list whom.*

As outlined in the Consent section, it is strongly recommended that you are under the care of a qualified healthcare professional who has confirmed that it is safe for you to participate in an exercise and weight loss program. This provider should also monitor any medications and health concerns you list here (aside from your weight issues, which we are addressing).

I acknowledge the above statement above. Sign*

Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc)

If questions below do not pertain please write NA

What medications, supplements and over the counter items do you take regularly or are currently prescribed*

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Any past surgeries and hospitalizations?*

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Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer*

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Do you exercise regularly? Please detail.*

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You have problems falling or staying asleep?*

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How is your energy?*

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What are your sources of stress?*

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Do you regularly drink alcoholic beverages?*

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If yes, how many per week?*

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Do you smoke tobacco?*

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Do you use recreational drugs?*

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How is your appetite?*

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How often do you eat out?*

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How often do you eat "fast foods"?*

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Food allergies?*

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Food cravings?*

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Do you drink coffee or tea? Yes No If Yes, how much daily?*

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Do you drink pop / soft drinks? If yes, how much?*

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Please list any food allergies, intolerances, or foods you avoid and the reason.*

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What past struggles and difficulties have you experienced in terms of food and dieting?*

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What diet and exercise programs, protocols, plans or approaches have you tried in the past?*

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What types of diet and exercise approaches have worked for you in the past?*

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What was your highest weight? (excluding pregnancy)*

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What was your lowest weight?*

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Have you ever stayed the same weight for 10 years or more?*

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How MOTIVATED are you to lose weight?*

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Is there anything else you would like to tell us?*

Please list the factors you feel have contributed to your current weight (check all that apply):

Family history of obesity*

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Family history of medullary, or pancreatic cancer*

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Comfort food dependency*

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Binge eating*

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Late night snacking*

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Medication related weight gain*

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Signature*