Options Weight Loss Long and Short-term Coaching Program


Options Weight Loss Coach - Patient IntakeRead the next weight Loss page

Patient Intake Form         Date_____________


Patient Name: (Last)                                                                      (First)                                                                    (MI)                      

Patient Address:                                                                                                                                                                                             

City:                                                                                                        Prov:                                     Postal Code:                     

Home Phone:                                                                                    Cellular:                                                                               

Birthdate:                                                                                             Age:                       Sex:  M     F

Education: Elementary  High School/Tech School   2-yr College   4-yr College   Grad. School (Circle Highest Level)


Employment Information:

Patient Employer:                                                                                             Occupation:                                                                      

Employer Address:                                                                                                                                                                                         

City:                                                                                                                        Prov:                                     Postal Code       ______

Work phone No:                                                                                                              Ext.                                                                       


In Case of Emergency:

Name:                                                                                   Relationship:                                      Phone:                                                               

Patient’s Spouse:                                                                                                                              Phone:                                                               

Family Physician:                                                                                                                               Phone:                                                               

Referred by:                                                                                                                                                                                                     


Past History: (Please check if you have had any of the following):

¨ Allergies, Type: __________________              ¨ Birth defects or abnormalities

¨ Measles                                                                         ¨ Scarlatina                        ¨ Influenza      

¨ Mumps                                                                           ¨ Diphtheria                     ¨ Rheumatic                                                    

¨ Fever German Measles (3 day)                            ¨ Polio                                 ¨ Whooping Cough                       

¨ Frequent Colds                                                            ¨ Chickenpox                   ¨ Tonsillitis                        ¨ Scarlet Fever

¨ Pneumonia                                                                   ¨ Diabetes: Type:                                                                          

¨ Cancer, Type:                                                               ¨ Other Diseases                                                                           

¨ Operations:( dates)                                                                                                                                                                                  

Current Medications (vitamins, birth control pills):                                                                                                                     

Any mood altering or depression medication:                                                                                                                        

Allergies to medicines, foods, etc                                                                                                                                                          


Family History:

Father: Health _____________ Age ______ Deceased _____ at age _____ Cause                                                        

Mother: Health _____________ Age ______ Deceased _____ at age _____ Cause                                                      

# of siblings:_______ # living______     #deceased: ________ Cause                                                                                    


Family Diseases: Check diseases known in your blood relatives (not yourself)

¨ High blood pressure ¨ Allergy                                             ¨ Heart trouble               ¨ Anemia

¨ Migraine                         ¨ Bleeding (abnormal)                                 ¨ Dropsy                            ¨ Epilepsy

¨ Strokes                           ¨ Cancer                                             ¨ Diabetes                         ¨ Nervous breakdown

¨ Kidney disease            ¨ Syphilis or (bad blood)              ¨ Suicide                            ¨ Obesity

¨ Arthritis                          ¨ Rheumatic                                     ¨ Fever              

¨ Other _________________________                                                                                                                                                          





Date of last physical examination ______________ Reason:                                                                                                     

Hospitalizations _________ Dates ____________  Reason:                                                                                                      

X-Rays: Chest ________Stomach                            _ Gallbladder                      Kidney                                 Colon                     

Other ____                                                                        Date of last laboratory tests:                                                                      

Electrocardiogram (heart tracing)                                             _  Date of last pap (cancer smear): ___________                                            

Do you now have or have had any of the following?

¨ Itching             ¨ Eczema                           ¨ Hives                                ¨ Joint pains                     ¨ Muscle aches

¨ Arthritis          ¨ Limitation of motion  ¨ Backache                        ¨ Leg pains                        ¨ Heel Pains

¨ Pain or stiffness (neck)                            ¨ Goiter                              ¨ Swelling, enlarged glands       

¨ Asthma           ¨ Lung disease                 ¨ Raise sputum               ¨ Emphysema Bronchitis                                            

¨ Heart trouble                                               ¨ High blood pressure ¨ Shortness of breath ¨ Palpitation or fluttering ¨ Chest pain   ¨ Lips or nails turn blue     ¨ Tire easily      ¨ Swelling of ankles      

¨ Indigestion    ¨ Nausea or vomiting   ¨ Abdominal pain           ¨ Gas or bloating            ¨ Diarrhea

¨ Hard bowel movements          No. of bowel movements - daily _____                                 ¨ Colitis

¨ Jaundice         ¨ Hemorrhoids (piles)  ¨ Bleeding or black stools                                           ¨ Hernia                            

¨ Urinary System                                            ¨ Kidney disease            ¨ Bladder disease           ¨ Kidney stones

¨ Painful urination                                         ¨ Pus or blood in urine ¨ Albumen or sugar in urine     

¨ Dribbling of urine                                        ¨ Varicose veins              ¨ Nervousness or anxiety          

¨ Trouble sleeping                                         ¨ Headaches                    ¨ Bored or depressed ¨ Nervous breakdown                

¨ Fainting                                                           ¨ Convulsions                  ¨ Numbness                     ¨ Loss of consciousness ¨ Neuritis or Neuralgia                                       ¨ Paralysis


Weight History:

When did you first become overweight?  (your age then)                                                             (year) _________

How did your weight gain start? Describe any circumstances:                                                                                                                                                                                                                                                                                                                                     

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

Your present weight: ______________ your weight goal:                                                           height:                                 

What was your highest weight? (excluding pregnancy) _______your age then                  # of years ago:                 

What was your lowest weight?                                                  Your age then                                    # of years ago:                                 

Have you ever stayed the same weight for 10 years or more?     Yes/ No

Have you attempted to lose weight before? ______ Most wt lost:                          how long it took: ____________

Describe previous methods of weight loss (e.g. diets, pills, injections, hypnosis, and acupuncture) and describe your results:                                                                                                                                                                                                                                                                                                                                                                                                                                                


Where and when do you do most of your overeating?                                                                                                                                                                                                                                                                                                                                                  

How many meals do you eat a day? ______     How many times do you snack a day? ________How many times a week do you eat out? ____ What foods do you eat when snacking? _____________________________________________________________________________________________________________

How motivated are you to lose weight now?           (1- none, 10 – very motivated)                                                                                                                                                                                                                                             

Do you currently have any medical concerns?  Please List:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               




Financial Policy:

Thank you for selecting Options Weight Loss Coach. We are honoured to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due in advance.


I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

I have read and understand all of the above and have agreed to these statements.

Patient’s Signature                                                                                             Date


All Statements on this patient intake form are accurate and true to the best of my knowledge.   I understand that treatments will be based on the information provided herein.   If I willingly withhold knowledge from my treating surgeon and clinical practitioners, I accept full liability from any consequences arising.  


Patient’s Signature                                                                      Date