Patient Consultation Questionnaire
Health Care Analysis
Step
1
of
3
33%
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Weight
*
Pounds (LBS)
Please enter a number greater than or equal to
0
.
Height (Feet)
*
Please enter a number greater than or equal to
0
.
Height (Inches)
*
Please enter a number greater than or equal to
0
.
Referring Clinic
*
Name of the clinic or company that is offering weight loss services
How did you here about us?
*
Select one
Social media
Seach engine (Google)
Physician
Family or friend
Print ad
Radio
Other
Questionnaire
Please answer the following questions honestly, so we can do our best to help you reach your goals.
How important is it to you to lose weight?
*
What important reason, special occasion, or goal date do you have to lose weight?
Who encouraged you to lose weight?
How many pounds would you like to lose?
*
Please enter a number greater than or equal to
0
.
How fast do you want lose the weight?
*
In weeks
Please enter a number greater than or equal to
0
.
Would you commit to one visit a week?
*
Yes
No
Have you ever attended any other weight reduction centers? If so, which ones?
What kinds of diets have you tried on your own?
What is the longest you have been able to stick with a diet?
In weeks
Please enter a number greater than or equal to
0
.
Does your family support your weight loss efforts?
*
Yes
No
Do you eat because of emotions?
*
Yes
No
Please explain
*
Have you been advised by your physician to lose weight?
*
Yes
No
Please explain
*
What is most important to you in deciding a weight loss program?
*
Please check all that apply
Effectiveness: “My results are my top priority”
Time: “I want results quickly”
Service: “I need extra support along the way”
Ease: “I have a difficult time losing weight”
On average, which of the following reflects your daily eating habits?
*
Please check all that apply
3 meals with healthy snacks
3 meals
2 meals or less
Skip breakfast or other meals
Generally eat on the run
No regular eating pattern
Often crave sweets/carbs
Graze; small, frequent meals
Current level of exercise
*
None
Light exercise (1-3 times per week, easy pace, stretching, walking, etc)
Moderate exercise (2-3 times per week, moderate pace, some weights, etc)
Heavy exercise (3-4 times per week, vigorous pace, weights, fast running, etc)
Past or present health conditions
Please check all that apply
Diabetes
Hypoglycemia
Strokes
Heart disease
High blood pressure
Hormone imbalance
Hormonal cancer
Thyroid imbalance
Anorexia
Bulimia
Drug addition
Currently pregnant or nursing
Allergic to sulfur, food, or medication
Vegetarion
Glaucoma
Please explain
*
Have you ever been hospitalized, under medical care, or checked into rehab for alcohol or drug treatment?
*
Yes
No
Please explain
*
Notes
Please provide any additional information that will help us determine what weight loss program is right for you.
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