Patient Intake Form

Weight Loss Questionnaire

Please complete before our consultation. If there are questions that you would prefer not to answer or you do not know the answer then just leave them blank.
Name

First NameLast Name
Date of Birth

MonthDayYear
Occupation
Contact Information
Address:

Street Address

Street Address Line 2

CityCounty/State/Province

Postal / Zip CodeCountry
Email
example@example.com
Preferred Phone Number

Health Assessment and Medical Information
Current Height
Current Weight
Has your weight ever fluctuated by more than 10lbs in a short period of time?

YesNoI have struggled with my weight now for years
Details, if applicable
Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..

YesNo
Type a question
Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?

YesNo
List here
Any known allergies?

Weight Loss Questionnaire