newageaestheticsandwellness.com - Medical Weight Loss Form

Medical Weight Loss

New Patient Intake Form
Patient’s Name
Date

MonthDayYear
HEALTH AND WELLNESS HISTORY
Has your doctor advised you to lose weight?
Please explain:
Do you have any dietary restrictions?
Please explain:
How often do you exercise?
What type of exercise do you do?
Do you feel stressed?
Please explain:
Check all that apply to you:
Please answer the following questions honestly so we can do our best to help you reach your goals.
What changed that caused the weight gain?
What’s the main reason you are seeking treatment at this time?
What are your goals about weight control and management?
What do you consider to be your ideal weight?
When was the last time you were at your ideal weight?
How much weight do you want to lose?
How many times a year do you diet?
What is the hardest part about managing your weight?
What have you tried in the past that has failed?
Have you maintained weight loss for up to a year with any of these programs?
What did NOT work for you about these programs?
What has been your lowest and highest weight as an adult?
What’s more important: inches lost or pounds?
What’s more important: fast or permanent?
How fast do you want to be slim, trim, and fit?
What would stop you from a weight loss program?
Do you binge eat?
Do you suffer from uncontrollable cravings?
Do you feel that food controls you?
Do you eat because of your emotions?
Do you eat between meals?
What do you choose to eat between meals?
Do you feel that your eating behaviors are normal?
Briefly describe your daily eating behaviors:
Does your family support your weight loss efforts?
Can you remember being at your ideal weight?
What do you remember most about it?
Commitment to weight loss:

1

2

3

4

5

6

7

8

9

10

1 is low, 10 is high
Please check all that apply:

Other
Current Medications:
Should be Empty:

Medical Weight Loss

HEALTH AND WELLNESS HISTORY