Click to
print this form. Please complete and bring with you.
| Full Name | __________________________________________________________________________ | ||||||
| Birthdate | month: ______________ day: __________ year: _________ | ||||||
| Address |
street:_____________________________________________________________________ city: __________________________________________ zip/postal code _______________ state/province: ________________ country: ______________________________________ |
||||||
| Stats: | Current Height: _______________ (circle one: CM or FT/IN) Current Weight: _______________ (circle one: KG or LBS) Most you have ever weighed: _______________ (circle one: KG or LBS) |
||||||
| Marital and parenthood Status: | Married ____ Widowed _____ Divorced _____ Single (never
married) ____ How many years? ________________ Do you have children: Yes ____ No ____ How many? _____ Do you plan to have children or have more children? Yes ____ No ____ What type of birth control are you using presently? (if none, write NONE on the line)__________________________________________________________________________ |
||||||
General Health Status: |
Do you have any of the following (check ALL that apply) _____ High Blood Pressure _____ Heart Problems _____ Asthma or other breathing problems _____ Diabetes (high blood sugar) _____ High Cholesterol _____ Thyroid Disease (Hyper/Hypothyroid, Graves Disease) _____ Obstructive Sleep Apnea _____ Depression (treated by a mental health professional) _____ Arthritis, Degenerative Joint Disease _____ Polycystic Ovarian Syndrome _____ Eating Disorder (anorexia, bulemia) _____ GERD (Gastroesophageal Reflux Disease) _____ Stomach Ulcers |
||||||
| Medications | List all medications including herbal remedies, vitamins,
nutritional supplements and over-the-counter drugs. If you need
additional space mark here ____ and use the back of this form.
1.
___________________________________________________________________ |
||||||
| Allergies | List all known allergies here including environmental (pollen,
animal dander, etc.) food and drug: If you need additional space mark
here ____ and use the back of this form.
1.
___________________________________________________________________ |
||||||
| Prior Surgeries | Please list your previous surgeries (types and dates) (example:
May 1999 - laparoscopic cholecystectomy) If you need additional
space mark here ____ and use the back of this form.
1.
___________________________________________________________________ |
||||||
| Other conditions | Please list other illnesses/diseases you have or have had: If you
need additional space mark here ____ and use the back of this form.
1.
___________________________________________________________________ |
||||||
| Weight Loss History | Please list the types and dates of diet programs you have tried and
the amount of weight lost on each: (example: Jan-April 1999 - Weight Watchers - lost 40 lbs) You may use the back of the form if you need more space. 1. ___________________________________________________________________ 2.___________________________________________________________________ 3.___________________________________________________________________ 4.___________________________________________________________________ |
||||||
| Exercise | How many hours per week do you exercise? _____________________ What types of exercise do you perform? ________________________________________ _______________________________________________________________________ _______________________________________________________________________ |
||||||
| Eating Habits | What kinds of food do you think you eat too much of? (check
ALL that apply)
Do you snack between meals? Yes _____ No ____ Do you binge eat? Yes ____ No ____ Do you eat when you're depressed? Yes ____ No ____ |
||||||
________________________________________________________
________________________
Signature
Date
click to close this window after printing.
copyright 2005: http://www.profweiner.com