Medical Weight Loss
New Patient Intake Form
Patient’s Name
Date
-
Month
-
Day
Year
HEALTH AND WELLNESS HISTORY
Has your doctor advised you to lose weight?
Yes
No
Please explain:
Do you have any dietary restrictions?
Yes
No
Please explain:
How often do you exercise?
What type of exercise do you do?
Do you feel stressed?
Yes
No
Please explain:
Check all that apply to you:
Pregnant
Might be Pregnant
Breastfeeding
Currently Undergoing Chemotherapy
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?
Yes
No
Do you suffer from uncontrollable cravings?
Yes
No
Do you feel that food controls you?
Yes
No
Do you eat because of your emotions?
Yes
No
Do you eat between meals?
Yes
No
What do you choose to eat between meals?
Do you feel that your eating behaviors are normal?
Yes
No
Briefly describe your daily eating behaviors:
Does your family support your weight loss efforts?
Yes
No
Can you remember being at your ideal weight?
Yes
No
What do you remember most about it?
Commitment to weight loss:
low
1
2
3
4
5
6
7
8
9
high
10
1 is low, 10 is high
Please check all that apply:
Abnormal periods
ADD/ADHD
Alcohol abuse
Food allergies
Anemia
Aneurysm
Anxiety
Autoimmune disorder
Asthma
Cancer
Celiac Disease
Chronic Fatigue
Depression
Diabetes (Type 1)
Diabetes (Type 2)
Eating disorder
Liver disease
Emphysema
Epilepsy/seizures
Fibromyalgia
Gall bladder disease
Goiter
Gout
Heart Attack
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDS
Irritable Bowel
Kidney stones
Low Blood Pressure
Low Blood Sugar
Migraine headaches
Raynaud's
Rheumatoid Arthritis
Stroke
Thyroid disease
Stomach ulcers
Thyroid cancer
Other
Current Medications:
Submit
Should be Empty: