Weight Management Intake Form

Name

Age

Date of birth

Phone Number (day)

Phone Number (evening)

Email Address

Primary Care Physician

Physician Phone Number

Adult Weight History

Height

Weight

BMI (if known)

Minimum Weight

Age when at minimum weight

Maximum Weight

Age when at maximum weight

Age at onset of weight problems?

Previous weight loss methods?

What is your reason for wanting to lose weight at this time?

Other than weight, what goals do you have for yourself in regards to your health and lifestyle?

Social Support System

Who do you live with?

Are they supportive of your decision to lose weight and how do you think they will be supportive?

Social History

If so, how much per day?

If so, how much per day/week/month/year?

If so, what and how often?

If so, which drugs and how often?

If so, what types of exercises and how often?

Do you walk a mile or more daily?

Medical History

Do you have any of the following? Please select all that apply and provide information for conditions selected under Group A in the area provided below the checkboxes.

Additional information regarding any conditions from Group A

Recent hospitalization and/or surgery (include dates)

LMP

How many past pregnancies?

Deliveries?

Any complications?

Current Medications

Please list all current medications that you take

Diuretics?

Insulin?