Weight Loss New Patient

Personal Health

Attitude
Do you have any negative feelings toward, or have you had any bad experiences with a nutrition or exercise program?*

YesNo
Please explain:*
Specifically describe what you would like to accomplish through monitoring your health during the next 1 month:*
Specifically describe what you would like to accomplish through monitoring your health during the next 4 months:*
Specifically describe what you would like to accomplish through monitoring your health during the next 1 YEAR:*
To improve your health in the past, what programs, "diets" supplements, medications, or professionals have you had SUCCESS with?*
Do you start a plan and find it hard to stick to?*

YesNo
Are you read to commit to a plan?*

YesNo

Adult Past Medical History
Check all that apply

HeartburnRefluxStomach ulcersHeadachesMigrainesAnemiaLiver diseaseColon diseaseBladder/Kidney disease
Anemia - Type*
Liver Disease - Type*
Colon Disease – Type*
Bladder/Kidney disease – Type*

Adult Past Medical History
Check all that apply

Alzheimer's Disease/Memory troubleSeizuresMuscle disorderJoint trouble/arthritisSickle cellSkin diseaseCancerAutoimmuneOther
Muscle disorder type*
Joint trouble/arthritis – Type (for example: Osteoarthritis)*
Skin disease – Type*
Cancer – Type*
Autoimmune - Type*

Surgeries -Check all that apply*

NONETonsilsAppendixGallbladderTubal ligationHysterectomyOther
Additional surgeries and dates:

New Weight Loss Patient