Weight Management Program Patient Application

Weight Management Program
Patient Application

General

First Name:

Last Name:

Date:

Address:

City:

State:

Zip Code:

Phone Home:

Phone Work:

Phone Cell:

Employer:

Occupation:

Emergency Contact:

Relationship:

Emergency Phone:

Age:

Date of Birth:

Sex:

Email Address:

(You will be subscribed to our monthly newsletter, you may unsubscribe at any time.)

How did you
hear about us?

TV:

Yes No

What Channel?

Radio:

Yes No

What Station?

Other Sources:

Internet Sites:

Referred by:

Newspaper / Flyer / Magazine:

Social History

Occupation

Position:

Nature of Work:

# of Years:

Marital Status

Single Divorced Long Term Partner Married Widowed

Date of Birth:

Sex:

Social Habits

Smoke

Yes No

When Stopped:

Packs per Day:

Coffee

Yes No

When Stopped:

Cups per Day:

Alcohol

Yes No

When Stopped:

Liquor per Day:
Beer per Day:
Wine Per Day:

Other Drugs

Yes No

When Stopped:

Amount per Day:

Meals

Regular:

Yes No

Meals per day:

Snacks per day:

Emotional Stress

At Work:

Family:

Other:

Exercise

None

Irregular

Type:

# Times/week:

Regular

Type:

# Times/week:

Sleep

Regular?

Yes No

Hours per night:

Do you snore?

Other relevant information that may have bearing on your lifestyle, in your own words:

Health History

Medical History:

Allergies:

SurgicalHistory
/Dates:

Weight History

What is your present weight?

What is your goal weight?

When did you first become over weight?

Age:

Year:

How did your weight problem start? How much did you gain and over what period of time?

What do you think is the cause of your weight problem?

What is your main reason for trying to lose weight?

Is your spouse or significant other heavy?

Are any family members heavy? If so please list them.

Describe your previous methods of weight loss if any. Describe the results.
How much did you lose? What did you do? How long did it take?

Please make any comments that you think might be helpful.

Food/Health Questionnaire

What kind of foods/meals do you usually eat?

Processed/fast foods Home made Others

If you eat processed/fast foods, how often?

Daily 2-3 times per week Once a week

List the kinds of foods you eat:

Do you eat/snack late at night?

Yes No

If yes, how often?

What do you eat/snack on?

Do you eat fruits and vegetables?

Yes No

How many times a day do you eat fruits and vegetables?

Are you a carbohydrate addict?

Yes No

Do you have cravings for foods, sweets, or chocolate?

Yes No

If none of these, what do you crave?

How often?

When do you have the cravings?
(For example during your cycle for women or when stressed)

Do you feel tired all the time?

Yes No

Do you know why?

Could it be due to overwork, stress, slow metabolism or something else?

Have you ever done a detox (internal cleansing) before?

Yes No

If yes, when was that?

How did you feel during and after the detox?

Are you presently on any antioxidant supplement?

Yes No

If yes, what kind?

How often do you take it?

If no, would you be interested ?

Yes No

Do you suffer from any of these digestive tract problems?

Bloating/gas	Poor digestion
Constipation	Tiredness
Heart burn	Other:

How often?

List the foods and drinks you had in the last 3 days

Day 1

Breakfast:

Lunch:

Dinner:

Day 2

Breakfast:

Lunch:

Dinner:

Day 3

Breakfast:

Lunch:

Dinner:

Who plans meals in the house?

Cooks?

Shops?

Do you use a shopping list?

Yes No

Are you interested in optimal health to prevent illnesses and anti-aging supplements to slow down the aging process?
Yes No

Consent

Consent to Use & Disclosure of Protected Health Information

Use & Disclosure of Your Protected Health Information:
Your protected health information will be used by Weight and Body Solutions, or to others for the purposes of treatment, obtaining payment, or supporting day-to-day health care operations of the practice.

Notices of Privacy Practices:
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.

Requesting a Restriction on the Use or Disclosure of Your Information:
You may request a restriction on the use or disclosure of your protected health information.
Weight and Body Solutions may or may not agree to restrict the use or disclosure of your protected health information. If Weight and Body Solutions agrees to your request, the restriction will be pending on the practice. Use or disclosure of protected health information in violation of an agreed upon restriction will be violation of the federal privacy standards.

Revocation of Consent
You may revoke this consent to use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date, on which your revocation of consent is received, will not be affected.

Reservation of Rights to Change Privacy Practices
Weight and Body Solutions reserves the right to modify the privacy practices outlined in the notice.

I have received this consent form and a copy of Weight and Body Solutions Notice of Privacy Practices. I also give my permission to Weight and Body Solutions to use and disclose my health information in accordance with it.

Patient Signature:

Date:

Patient Representative Signature:

Date:

Relationship of Patient Representative: