Weight Loss Nutrition New Patient Questionnaire
Today's Date
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Month
-
Day
Year
Date
Date of Birth
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Month
-
Day
Year
Date
Full Name
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First Name
Last Name
Select the program you are participating in
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Weight Loss and Nutrition
Nutrition only
Present Weight
Height
Desired or Ideal Weight
When would you like to be at your desired weight?
Why do you want to lose weight? (i.e. Heath Benefit, Appearance)
When did you begin gaining weight and why?
What has been your maximum weight (non-pregnant) and when?
Have you tried other weight loss or nutrition programs and/or medications?
Yes
No
If yes, which ones?
Were you successful with it?
Yes
No
Please explain.
Is your spouse, fiance, or partner overweight?
Yes
No
N/A
If yes, by how much is he/she overweight?
How often do you eat out?
What restaurants do you frequent?
How often do you eat "fast foods"?
Food restrictions
Food cravings
Do you eat because of emotions?
Yes
No
If yes, explain.
Do you drink coffee or tea?
Yes
No
If yes, how much daily?
Do you drink soft drinks?
Yes
No
If yes, how much daily?
Do you use sugar substitutes?
Yes
No
If yes, what?
What are your worst food habits?
Favorite snacks
When do you snack?
How much?
Describe your energy level.
Activity Level
Please Select
Inactive
Light Activity
Moderate Activity
Heavy Activity
Vigorous Activity
Commitment Level to making a change in your life today (1 = less committed; 10 = most committed)
Low Committment
1
2
3
4
5
6
7
8
9
High Committment
10
1 is Low Committment, 10 is High Committment
Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).
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