New Patient Weight Loss Intake

Check all that apply

Constant HungerSugar CravingsCarb CravingsSlow MetabolismFatigue / Low EnergyDifficulty Losing WeightWeight Gain Around StomachBloatingIrregular Bowel HabitsBrain FogSleep ProblemsStress / Emotional EatingWater Retention / SwellingIrregular Menstrual CyclesHot Flashes / Menopause SymptomsThyroid ConcernsFamily History: diabetes, thyroid disease, obesity

Daily Meals:

1 meal/day2 meals/day3 meals/day4+ meals/day

Snacking Frequency:

Rarely1 - 2 /day3 - 4/dayFrequent Grazing

Water Intake:

cups/day

Caffeine Intake:

None1 - 2/day3 - 4/day

Alcohol Intake:

NoneOccasionallyWeeklyDaily

Food Restrictions / Allergies

Check all that apply

Surgeries / Hospitalizations / Major Illnesses

Current Medications

Supplements

Are you Pregnant?

YesNo

Date Of Last Menstrual Period

Date

Cycle Regularity:

RegularIrregularPerimenopauseMenopause

WEIGHT-LOSS PROGRAM INTAKE FORM

PATIENT INFORMATION

PRIMARY HEALTH INFORMATION

WEIGHT-LOSS GOALS & HISTORY

Metabolic & Hormonal Symptoms Checklist

Nutrition & Eating Habits

Medical History

For Women Only