Weight Loss Program Participant Intake Form

Weight Loss Program Participant Intake Form
General Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*
Format: 0000-00000.
Gender
How will you be checking in?*
How did you hear about this program?
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Personal History
What are your main interests and hobbies?
What is your line of work or study?
Do you exercise regularly? Please detail.
What kind of other movement or activities do you enjoy?
You have problems falling or staying asleep?
How many hours do you sleep?
Do you wake up refreshed?
How is your energy?
Does your energy level affect your daily activities?
How would describe your mood, generally:
Does your mood affect your life or daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have people close to you who support you?
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
What is a typical day, in terms of food intake? Please list all meals and snacks.
How much fluids do you normally drink? Please approximate in ounces.
Please list all types of beverages you regularly drink.
Please list any food allergies, intolerances or foods you avoid and the reason.
What past struggles and difficulties have you experienced in terms of food and dieting?
What diet and exercise programs, protocols, plans or approaches have you tried in the past?
What types of diet and exercise approaches have worked for you in the past?
And what hasn't worked for you at all?
Let's get a current picture of your health

Health History*

Rows	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation
Diarrhea
Daily bowel movements

What are your top preferences for checking in?

Rows	Top choice	Works ok	Doesn't work for me
Monday morning (9am-noon)
Monday afternoon (noon-6pm)
Tuesday morning (9am-noon)
Tuesday afternoon (noon-6pm)
Wednesday morning (9am-noon)
Wednesday afternoon (noon-6pm)
Saturday morning (10am-noon)
Saturday afternoon (noon-5pm)

The above are my standard office hours of operation. If none of the above work, please list days and times that would and I will try to work something out with you.
I have read the following documents (are in the pdf version of this intake), fully understand them and agree to their terms (please sign with your cursor below). Documents: Rules & Responsibilities, Acknowledgement and Consent to Privacy Practices and Consent to Limited Treatment.*
Should be Empty:

Weight Loss Program Participant Intake Form

General Information

Medical History

Personal History

Diet and lifestyle

Let's get a current picture of your health