* Weight Loss Program Start Date
* Please list any pre-existing medical conditions. If none, answer N/A:
* Has a medical professional ever advised you to lose weight?
* Do you have any dietary restrictions?
* How many minutes per week do you exercise? (Put 0 if none)
What type of exercise do you typically do?
* How often do you feel stressed? (Ex: Daily, 2x per week, always, etc)
* Do you eat more or less when you are feeling stressed?
* Please check all of these that apply to you:
* Are you currently undergoing any specialized treatments? (Ex: chemotherapy, infusion therapy, etc)
Please answer the following questions honestly about yourself. This helps us to better help you reach your goals.
* Do you notice weight gain in correlation to lifestyle changes?
* What do you consider your ideal weight?
* When was the last date (as close as you remember) that you were at your ideal weight?
* What is the total amount of weight you would like to lose?
* What diets have you tried in the past? (List all whether they were successful or unsuccessful) If none, answer NONE.
* Have you ever experienced weight loss with a previous diet?
How long did you maintain the weight loss with previous diets?
* What is the hardest part about managing your weight?
* Which is more important to you?
* Which is more important to you?
* How quickly do you want to be slim, trim, and fit? (Ex: a few weeks, a few months, etc)
* What would stop you from participating in a weight loss program? Please explain.
* Which of the following statements is the MOST important element in deciding to use our weight loss services?
Please select which of the following condition(s) you'd like help with or more information on:
* Please list all medications. Include dosage and how long you've taken the medication. Include prescription, over the counter medications, vitamins, supplements, etc. If none, answer NONE.
* Please list all food and drug allergies and your reaction to them. If none, answer NONE.
* Please select ALL medical conditions that you currently have or have had in the past:
* What was the date of your most recent labs? Please include month and year.
* Please list all surgeries and dates of surgeries to include the month and year. If none, answer NONE.
If yes, please select how often.
* Do you use tobacco products?
If you are a current or former tobacco user:
Current user - What year did you start using tobacco products?
Former user - How many years did you use tobacco products?
Privacy and Sharing of Information
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
After submitting this form, you will be automatically redirected to another site to schedule your appointment with Gold Star Urgent Care.
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