Weight loss Questionnaire

Weight Loss Questionnaire

Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
First Name*
Last Name*
Nickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Mobile phone number*
Date of Birth and Age*
What is your height and current weight?*
1. What is the main reason you are seeking treatment at this time?*
2. What are your goals about weight management?*
3. Your level of interest in losing weight is.. (1=not interested 5=very interested)*
4. Are you ready for lifestyle changes to be a part of your weight control program? (1=not interested 5=very interested)*
6. What is the hardest part about managing your weight?*
7. What do you believe will be the most helpful in helping you to lose weight?*
8. What has been your lowest and highest body weight as an adult? *
Please check all previous programs that you have tried in order to lose weight*

Weight watchersLiquid DietsKeto DietDiet Pills (Phen - Fen)Nutrisystem/Jenny CraigDetox/CleanseObesity/SurgeryOther
Have you maintained any weight loss for up to 1 year on any of these programs?*

YesNo
What did you learn from these programs regarding your weight?
What did not work about these programs, so we can make changes?
What factors led to your success?
How does being overweight affect you?*
What has made weight loss difficult?*
What beverages do you drink daily and how much? Water/Coffee/Tea/Soda/Alcohol/Other:
Would you like to change your eating habits?*

YesNo
What habits would you like to begin to change?
What can't you do now that you would like to do if you weighed less?*
What would you like to get out of this visit regarding your weight?*
What's more important: inches lost or pounds?*
Does being overweight and unhealthy limit your activities?

YesNo
Do you eat in between meals?

YesNo
How much weight do you want to lose?*
Do you feel that your eating behaviors are normal?

YesNo
Briefly describe your daily eating behaviors:
Do you feel tired, run down, or out of energy?

YesNo
Please explain:
How fast do you want to be slim, trim, and fit?*
What is more important to you: fast or permanent?*
What would stop you from completing a weight loss program?*
Commitment to weight loss (rate from 1-10, 1 being low, 10 being high)*
Check the following conditions you would like help with or more information on:*

Neck or back painKnee painShoulder painHip painMigraine/HeadacheNeuropathyPlantar FascitisFatigueIV nutritionAllergy testingOther
What is the most important element in deciding to use our services? Check only ONE of the four answers:*

EFFECTIVENESS: "My results are my top priority."TIME: "I want results quickly."SERVICE: "I need extra support along the way."AFFORDABILITY: "I need this to be affordable."
Medical History
Current Medical Providers: *
Medical History*

OsteoporosisHeart diseaseDiabetesCancerDepressionStrokeParkinson's DiseaseAlcoholismAnemiaArthritisAnorexiaMultiple SclerosisMigraine HeadachesRheumatoid ArthritisThyroid problemsAsthmaBleeding DisordersBulimiaEmphysemaEpilepsyHerniaHerniated DiscHigh CholesterolKidney DiseaseLiver DiseasePacemakerAIDS/HIVPrevious Chiropractic careLow back painNeck painFibromyalgiaBalance issuesAnxietySinusitisAllergiesTMJOther
Family Health History

Heart diseaseDiabetesCancerDepressionStrokeParkinson's DiseaseAlcoholismArthritisThyroid problemsBleeding DisordersChemical DependencyEpilepsyHigh CholesterolKidney DiseaseLiver DiseaseOther
Informed Consent for Treatment
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient.
Signature*

Clear
Date*

MonthDayYear
Date
Release of Information
This is a confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Primary Policy Holder
Insurance Card (Front)

Cancelof
Insurance Card (Back)

Cancelof
Should be Empty:

Weight Loss Questionnaire

Patient Information

Medical History

Informed Consent for Treatment

Release of Information

Insurance Information