Rewind Health History Form

  • Rewind Health History Form

    Now that we've confirmed you could be a good fit for our program, let's gather some health history info for our clinical team to review.
  • What is your date of birth?*
     - -
  • Do you have a preferred method of contact if we need to get in touch with you?
  • All of our doctor and dietitian visits take place virtually using Zoom. Have you ever used Zoom on your phone before?*
  • What kind of phone do you have?*
  • What sex was originally listed on your birth certificate?*
  • What gender do you identify as today?
  • What are your pronouns?
  • What is your Race / Ethnicity? Select all that apply.*

  • Weight Loss History

  • Which do you feel most accurately describes your birth weight?*
  • Rows
  • Does anyone in your immediate family also have excess weight?*

  • Diabetes History

  • Have you been diagnosed with Type 2 Diabetes?*
  • When were you diagnosed with type 2 diabetes? Approximate date is fine if you're not sure.
     - -
  • What were the circumstances surrounding your diagnosis?
  • Do you have any diabetes-related complications?*
  • Do you have any of the following medical issues?*
  • Have you had any of the following labs done within the past year? If yes, we will ask you to share the results below.*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Social History

  • Have you ever smoked cigarettes?
  • What is your current alcohol intake on a weekly basis?

  • Do you currently or have you used any of the following drugs in the past?

  • Marijuana
  • Cocaine
  • Heroin
  • Meth
  • Are you currently employed?
  • Are you:
  • Are you sexually active?
  • Do you have more than one partner?
  • Is your partner:

  • Reproductive Health History

  • Date of Last menstrual period, if pre-menopausal.
     - -

  • Eating Patterns

    The following questions ask about your eating patterns and behaviors within the last 3 months. For each question, choose the answer that best applies to you.
  • During the last 3 months, did you have any episodes of excessive overeating (i.e., eating significantly more than what most people would eat in a similar period of time)?*
  • Do you feel distressed about your episodes of excessive eating?*
  • Within the past 3 months during your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g., not being able to stop eating, feel compelled to eat, or going back and forth for more food)?*
  • Within the past 3 months during your episodes of excessive overeating, how often did you continue eating even though you were not hungry?*
  • Within the past 3 months during your episodes of excessive overeating, how often were you embarrassed by how much you ate?*
  • Within the past 3 months during your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterwards?*
  • Within the past 3 months, how often did you make yourself vomit as a means to control your weight or shape?*
  • Which health outcomes or goals do you feel most motivated to achieve?*
  • How many meals per day do you typically eat?*
  • What are your typical portion sizes for meals?*
  • Which eating behaviors or patterns apply to you on a regular basis?*
  • How many snacks per day do you typically eat?*
  • How would you generally describe your snacking pattern?*
  • How often per week do you typically eat out?*
  • Do any environmental factors tend to trigger eating, hunger or cravings?*
  • Which factors do you feel are keeping you from achieving your weight/health goals?*

  • Pharmacy & Primary Care Doctor Info

    A few last questions.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • The cost of meal replacement shakes is about $8.72/day (or $1.74/shake). Keep in mind this will replace all your food costs (at least for yourself) during the first 3 months. Does this fit within your budget?*

  • No problem. We will have someone on our team reach out to you about financial assistance.

  • That's it! Thanks for completing your Health History. Our team will review and follow up.

  • Should be Empty: