Weight Loss New Patient

  • New Weight Loss Patient

  • IF YOU HAVE PROBLEMS filling out this online form, please use the printable form on our website! You can find it by clicking here.

  • Patient Information Sheet

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  • Birth Sex*
  • Are you currently pregnant or breastfeeding?*
  • Format: (000) 000-0000.
  • Marital Status*
  • Opt into email updates?
  • How did you hear about gerstenberg.clinic?

  • In Case of Emergency

  • Format: (000) 000-0000.

  • Motivation

  • What are your primary goals for living a healthier lifestyle? (check all that apply)
  • Combatting one or more of the following (check all that apply)

  • Personal Health

    Food Habits and Needs
  • Are you a diabetic?*
  • Do you consider yourself to be healthy?*
  • Do you feel that you eat nutritious foods most of the time?*
  • How often do you cook at home?*
  • Do you cook for other household members?*
  • Do you have any allergies or dietary restrictions?*
  • Do you need to daily monitor sugar, salt, or fluid intake?*
  • Have you ever had surgery for weight loss?*

  • Personal Health

    Lifestyle
  • Do you work night shifts?*
  • Does your job require that you sit at a desk?*
  • Do you have a regular sleep schedule?*
  • In the past year, how often do you exercise?*
  • Are you currently involved in regular exercise?*
  • Do you have any issues with mobility?*

  • Personal Health

    Attitude
  • Do you have any negative feelings toward, or have you had any bad experiences with a nutrition or exercise program?*
  • Do you start a plan and find it hard to stick to?*
  • Are you read to commit to a plan?*

  • Adult Past Medical History

  • Check all that apply
  • Diabetes - Type*

  • Adult Past Medical History

  • Check all that apply

  • Adult Past Medical History

  • Check all that apply
  • Surgeries -Check all that apply*
  • Do you have known drug allergies?*
  • Do you consume alcohol?*
  • Do you use tobacco?*
  • Do you have a living will?*
  • Employment status*

  • Family History

  • Does/did your Father have any of these conditions?
  • Does/did your Mother have any of these conditions?

  • Father's Parent's Medical History

  • Does/did your Paternal Grandfather have any of these conditions?
  • Does/did your Paternal Grandmother have any of these conditions?

  • Mother's Parents Medical History

  • Does/did your Maternal Grandfather have any of these conditions?
  • Does/did your Maternal Grandmother have any of these conditions?
  • Should be Empty: