Weight Loss Intake Form

Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name*

PrefixFirst NameMiddle NameLast Name
Gender*
Date of Birth*

DayMonthYear
Do You Have a Valid Ontario Health Card (OHIP)?*

YESNO
Ontario Health Card Number (OHIP)*
Version Code*
Email*
example@gmail.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityProvince

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 lifeTo improve in my health conditions.Other
Explain here
What treatments are you interested in pursuing? Check all that apply:

Lifestyle changes onlyLifestyle changes and weight loss medicationsI’m open to surgical weight loss
What is your weight loss goal?
Weight History
Normal weight upon birth?

YesNo
Normal weight during childhood?

YesNo
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 gainI quit smoking with associated weight gainPast or present medications associated with weight gain
Female patients only:

I have post-partum weight retentionI 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?

YesNo
Do you have excessive hunger within 1-2 hours of having a regular meal?

YesNo
There are times when I eat and it feels like I can’t stop.

YesNo
I eat for comfort when I am stressed or emotional.

YesNo
I try to manage my weight by vomiting, using laxatives, diuretics, or excessive exercise.

YesNo
Sometimes I find food on my bed which I do not remember eating.

YesNo
I eat late at night or I wake up at night and eat.

YesNo
Physical Activity History
At work I am?

Constantly moving.Somewhat activeNot active
I exercise regularly.*

YesNo
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

YesNo
I have done self-harming behaviors such as cutting myself:

YesNo
Have you been to the ER or hospitalized for mental health reasons

YesNo
Any alcohol or substance abuse, including prescription abuse

YesNo

PHQ-9 (depression questions)

Rows	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?

YesNo
Please provide the list of your allergies below*
Do you use any medications?*

YesNo
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.*

Medical History

Rows	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

MonthDayYear
Date
Current contraceptive/Birth control use:

Oral contraceptionIUD (Mirena, copper IUD)Tubal ligation (tubes tied)Hysterectomy and/or ovaries removedNone
Is there a specific medication you would like to request?*

YesNo
What is your requested medication name and dose?*
Do you agree to receive text reminders for your appointment?*

YesNo

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.*

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

$450.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Appointment Form

Weight Loss Motivations & Goals

Weight History

Diet History

Physical Activity History

Sleep History

Stress/Mood History

Medical History

Female Patients Only