Appointment Form
Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name
*
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Mrs.
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First Name
Middle Name
Last Name
Gender
*
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Female
Not willing to Disclose
Date of Birth
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Day
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1928
1927
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1925
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1923
1922
1921
1920
Year
Do You Have a Valid Ontario Health Card (OHIP)?
*
YES
NO
Ontario Health Card Number (OHIP)
*
Version Code
*
Email
*
example@gmail.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Weight Loss Motivations & Goals
What is your main reason for obesity treatment? Check all that apply:
I want this for myself (“self-motivation”).
A family member insisted that I lose weight.
My physician has recommended weight loss.
Other
Explain here
What is your motivation for obesity treatment? Check all that apply:
To improved appearance.
To be more active.
To have a better quality of life
To improve in my health conditions.
Other
Explain here
What treatments are you interested in pursuing? Check all that apply:
Lifestyle changes only
Lifestyle changes and weight loss medications
I’m open to surgical weight loss
What is your weight loss goal?
Weight History
Normal weight upon birth?
Yes
No
Normal weight during childhood?
Yes
No
What is your highest adult weight?
What is your lowest adult weight?
Your lowest adult weight happened with diet or weight loss program or both?
explain here
Please describe when and how you started gaining weight?
Is there evidence of a genetic history of obesity? Check all that apply:
There is a strong family history of obesity.
Obesity started early and has been progressive during my life.
I was excessively hungry as a child.
Are there any other reasons for weight gain? Answer any that apply.
Shift work with associated weight gain
I quit smoking with associated weight gain
Past or present medications associated with weight gain
Female patients only:
I have post-partum weight retention
I have menopause associated weight gain of
Diet History
What diets have worked for you in the past? Please list all that apply.
Are you currently working with a Registered Dietitian?
Yes
No
Do you have excessive hunger within 1-2 hours of having a regular meal?
Yes
No
There are times when I eat and it feels like I can’t stop.
Yes
No
I eat for comfort when I am stressed or emotional.
Yes
No
I try to manage my weight by vomiting, using laxatives, diuretics, or excessive exercise.
Yes
No
Sometimes I find food on my bed which I do not remember eating.
Yes
No
I eat late at night or I wake up at night and eat.
Yes
No
Physical Activity History
At work I am?
Constantly moving.
Somewhat active
Not active
I exercise regularly.
*
Yes
No
Type of exercise that I usually do (if applicable)
The physical activities I enjoy are?
Number of times I exercise in a week?
Amount of time I exercise
Sleep History
How many hours do you sleep at night in average?
Stress/Mood History
My stress level during the past year on a scale of 1 to 10?
When I feel stressed I tend to?
The main cause of my stress is?
Any thoughts about harming yourself or wanting to die
Yes
No
I have done self-harming behaviors such as cutting myself:
Yes
No
Have you been to the ER or hospitalized for mental health reasons
Yes
No
Any alcohol or substance abuse, including prescription abuse
Yes
No
PHQ-9 (depression questions)
Not at all - 0
Several days - 1
More than half of days - 2
Nearly every day - 3
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling asleep, staying asleep or sleeping too muchs
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself/family down
Trouble concentrating on things such reading or watching
television
Moving or speaking so slowly that people have notice or
being so fidgety or restless that you have been moving
around a lot more.
Thoughts that you would be better off dead or of hurting
yourself.
Medical History
Do you have any food or drug allergies?
Yes
No
Please provide the list of your allergies below
*
Do you use any medications?
*
Yes
No
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.
*
Medical History
Yes
No
History of Glaucoma?
History of Palpitations?
History of Chest pain?
History of Headaches?
History of Kidney Stones?
History of Seizures?
History of Head trauma?
History of radiation to the brain?
History of Pancreatitis?
Personal or family history of thyroid cancer?
Female Patients Only
Date of your last period
-
Month
-
Day
Year
Date
Current contraceptive/Birth control use:
Oral contraception
IUD (Mirena, copper IUD)
Tubal ligation (tubes tied)
Hysterectomy and/or ovaries removed
None
Is there a specific medication you would like to request?
*
Yes
No
What is your requested medication name and dose?
*
Do you agree to receive text reminders for your appointment?
*
Yes
No
Weight-Loss (Non-OHIP) Visits – If you have a valid OHIP card, your visit is free. Please enter your card information in the required field above.
*
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Care365.CA
This is a service fee for NON-OHIP patients. This payment is non-refundable if the patient does not attend the meeting or miss the meeting
$
450.00
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
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