Weight Loss Program Participant Intake Form

General Information

First Name

Last Name

Birth Date

Street Address

Street Address Line 2

City

State/Province

Postal / Zip Code

E-mail

Phone Number

Gender

How will you be checking in?

On line (face time)

Phone

In Office

How did you hear about this program?

Medical History

Are you under the care of a qualified healthcare professional? Please list whom

What medications, supplements and over the counter items do you take regularly or are currently prescribed:

Any past surgeries and hospitalizations?

Personal History

What are your main interests and hobbies?

What is your line of work or study?

Do you exercise regularly? Please detail.

What kind of other movement or activities do you enjoy?

You have problems falling or staying asleep?

How many hours do you sleep?

Do you wake up refreshed?

How is your energy?

Does your energy level affect your daily activities?

How would describe your mood, generally:

Does your mood affect your life or daily activities?

How would you describe your stress level?

What are your sources of stress?

How do you manage stress?

Do you have people close to you who support you?

Diet and lifestyle

Do you regularly drink alcoholic beverages?

Yes No

If yes, how many per week?

Do you smoke tobacco?

Yes, 1+ pack per day Yes, 1/2 pack per day Yes, less than 1/2 pack per day I have quit I have never regularly smoked

Do you use recreational drugs?

How is your appetite?

How many meals per day do you eat?

What is a typical day, in terms of food intake? Please list all meals and snacks.

How much fluids do you normally drink? Please approximate in ounces.

Please list all types of beverages you regularly drink.

Please list any food allergies, intolerances or foods you avoid and the reason.

What past struggles and difficulties have you experienced in terms of food and dieting?

What diet and exercise programs, protocols, plans or approaches have you tried in the past?

Drug Allergies

Food Allergies

Are you Pregnant?

Yes No

Breast feeding?

Yes No