SLIM TLC® w/o Meds New Patient Form
For best care and outcomes, please complete as thoroughly and accurately as possible.
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
How did you hear about SLIM TLC® (if word of mouth, please include name)?
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Medical conditions (please include all)
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Type "None" if applicable.
Medications (please include all prescription and over-the-counter meds)
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Type "None" if applicable.
Current Weight
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Height
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Ultimate Goal Weight
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To calculate your BMI, visit https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Short-Term Goal Weight
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Please indicate:
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I do not have a specific dietary preference and am open to what you think is best.
I have the following dietary preference (e.g., vegetarian, South Beach, Paleo):*
*Dietary Preference:
How would you describe your eating habits?
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How often do you eat out?
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0-1 time per week
2-3 times per week
4-5 times per week
6 or more times per week
How many sugared beverages do you drink on average per day (including juice)?
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How much alcohol do you usually drink (include how often)?
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About what percentage of your diet consists of "whole" plants?*
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*Whole means eaten whole or prepared healthily, i.e., without any sugar, oil, white flour, or animal products.
Describe your level of physical activity and exercise type/frequency?
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What are your hobbies and interests?
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What is the most you have ever weighed?
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What were the circumstances surrounding that weight gain?
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What is currently motivating you to lose weight, i.e., why is it important to you?
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Describe any weight loss efforts you have made, or programs you have tried, in the past:
Is there anything else you would like us to know about you, or any concerns that you have?
To Do List (check each one)
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I will set up a 25-minute Nutrition Coaching appointment with Marie (BS) by clicking on the link below.
I will try to attend at least one SLIM TLC® group visit (in-person or virtual) every month.
I will try to carefully review at least one TLC University lesson each month and take (and submit) the associated quiz.
I will begin to think of two people (to round out your "TLC Trio") to invite to join me on this journey.
I will try to learn and implement the SLIM TLC® eating strategy called "Free Food? Whatever!" (see Lesson #2 of TLC University - part of SLIM TLC® Online).
I will try to complete and follow as many components of the "SLIM TLC® Map" (the goal-setting system found in Lesson #3 of TLC University - part of SLIM TLC® Online) as is necessary to help guide me towards long-term success. I will submit my SLIM TLC® Map monthly through the Elation Passport patient portal.
I understand that the above components are critical to developing longstanding Therapeutic Lifestyle Changes, which are necessary if I hope to maintain any weight loss I achieve.
Regarding the SLIM TLC® Map:
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I am comfortable with you using my SLIM TLC® Map, minus any visible personally identifiable information, in your educational or promotional materials, and to extract data for the same or for research purposes.
I would not be comfortable with you using my SLIM TLC® Map in your educational or promotional materials, but I would be comfortable with you extracting data (minus any personally identifiable information) for educational or promotional materials, or for research purposes.
Book a 25-minute Nutrition Coaching appointment with Marie
Please let us know if you have any questions or concerns:
See you thin!
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