Application for Weight Loss Program

Application for Weight Loss Program

Patient Intake Form
Date

MonthDayYear
Date
Do you have a free consultation appointment scheduled?*

YesNo
Name*

First NameLast Name
Preferred First Name
Check All That Apply

MaleFemaleMinorSingleMarriedWidowedSeparatedDivorced
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Phone Number*

Area CodePhone Number
Best time to contact me / AM or PM / Home or Cell
Email Address
example@example.com
** We will not sell or distribute your email address to any 3rd parties. Emails are used for communication from our company exclusively**
Date of Birth*

MonthDayYear
Date
Who can we thank for referring you?
If you were not referred, how did you hear about us?
If RADIO selected, which station?
If OTHER selected for how did you hear about us, please list source here.
How Did You Hear About Us?*

Radio: Freddy Mac-Q102-101.9 WKRQ-FMRadio: Grover/Holly-B105-105.1 WUBE-FMInternet SearchReferralFacebook/InstagramOther
Please tell us who referred you.
Please specify where you heard about us.
What is your preference for Appointment Reminders?

Text OnlyCall OnlyBoth Text & Call
Weight Loss Questionnaire

Please be as detailed as possible. This information helps us understand your specific needs.
1. What is your current weight*
Pounds
2. What is your height (in feet and inches)
Example: 5-8
3. What is your waist measurement (use pants size if exact measurement is unknown)
inches
4. How much weight are you looking to lose?*
5. Is there a reason you are wanting to lose weight at this time?*
Ex: Wedding, health scare, fed up, etc.
6. What are your goals about weight control and management?*
Ex: Improve health, long term maintenance, etc.
7. Your level of interest in losing weight is:*

1 Not Very Interested2345 Very Interested
8. Are you ready for lifestyle changes to be a part of your weight control program?*

1 Not Very Interested2345 Very Interested
9. How much support can your friends and family provide?*

1 Not Much2345 Very Much
10. What is the hardest part of managing your weight?*
Ex: Social engagements, stress, too busy, etc.
11. What do you believe will be the most critical strategy in helping you to lose weight?
Ex: Easy to follow diet, support and accountability, etc.
12. Do you have any specific goals other than weight loss?
Ex: Improve health, fit in clothes, etc.
13. What has been your lowest weight as an adult?
14. What has been your highest weight as an adult?
15. Have you tried to lose weight before?*

YesNo
16. At what age did you start trying to lose weight?
17. Please check all previous programs that you have tried in order to lose weight.*

GLP-1 Medications (Oxempic, etc.)Weight WatchersOvereaters AnonymousLiquid DietsDiet Pills (Meridia, Xenical)Diet Pills(Phen-Fen,Redux)Nutrisystem/JennyCraigOTC Diet PillsRegistered DieticianWeight loss SurgeryOther
18. Have you maintained weight loss for over 1 year on any of these programs?*

YesNo
19. What did you learn from these programs regarding your weight?
20. What did not work about these programs?*
Ex: Group meetings, products made you jittery, etc.
21. How important is it that you lose weight at this time?*

Not at allNot VerySomewhatVery importantImperative
22. What factors led to your success in the past?

Encouragement from othersPersonal determinationUpcoming goal (ex: vacation or wedding)Clearly defined weight loss milestonesI have never truly been "successful"
23. How does being overweight physically affected you?

Medical issuesLimits exerciseI Can’t wear the clothes I likeI feel tired or fatiguedMy knees hurtMy back hurtsCertain activities feel like a "chore"
24. What can’t you do now that you would like to do if you weighed less?

Walk comfortablyClimb stairsExercise (like run or ride a bike for distance)Recreational sports (like golf, tennis or bowling)Play with my children/grandchildrenGet into my old clothes
25. How has being overweight emotionally affected you?

I don't like shopping for new clothesI avoid having my picture takenI avoid certain social situationsI feel embarrassed about my weightI have a less than ideal self-worth
26. If you reached your goal weight how would you feel emotionally?

I would engage in social activities more oftenI would enjoy social activities moreI would feel more comfortable in less clothes (ex: bathing suit)I would have more confidenceI would have a more positive self-image
27. What has made weight loss difficult?*

TravelHolidaysWeekendsPartiesHungerCostPeer PressureFamily
28. What is hard about managing your weight?

No will powerI’ve always been overweightCan't exerciseSchedule too busyHungry all the timeI don’t like vegetablesI’m a meat & potatoes personI’m addicted to sugarI like beer
29. Do you follow a special diet?*

NoDiabeticLow SodiumLow fatKosherVegetarianOther
30. What meals do you eat regularly?

BreakfastBrunchLunchDinnerSnack throughout the day
31. What are your favorite snack foods?
Ex: Chips, sweets, etc.
32. Do you typically eat out or cook for yourself?

Eat outCookBoth
33. How many times per day do you have the following items?

TIMES PER DAY
Starch (bread, cereal, pasta, rice, noodles, potatoes)
Fruit
Vegetables
Dairy (milk, yogurt, cheese)
Meat (fish, poultry, eggs)
Fat (butter, margarine, mayonnaise, oil, salad dressing, sour cream, cream cheese)
Sweets (candy, cake, regular soda, juice)
34. What beverages do you drink daily and how much?

TIMES per day OR 8 OZ GLASSES per day
Water
Coffee
Tea
Soda
Alcohol
Juice
35. Would you like to change your eating habits?*

YesNo
36. What habits would you like to begin to change?
Ex: Eat less, understand healthier options, etc.
37. Is your decision to lose weight your own or for someone else?*

MineMy SpouseMy Healthcare ProfessionalMy ParentsMy Friends
38. What would you like to get out of a weight loss program?*

An easy to follow meal planSupport and accountabilityLifestyle guidanceUnderstanding about what makes me gain weightMedication/weight loss aidsEvaluation of what triggers poor eating habits
39. We want to get to know you! Please let us know anything else about YOU that is important.
Should be Empty:

Application for Weight Loss Program

Weight Loss Questionnaire