Options Weight Loss
Long and Short-term
Coaching
Program
Options
Weight Loss Coach - Patient Intake
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
_________________________
Examinations:
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