Can we call you at work?
Do you prefer to have appointments confirmed by:
3. Is today's problem caused by an:
4. Indicate on the drawings below where you have pain/symptoms
(appear a red circle on the location by clicking on it):
5. How long have you had this problem?
6. How often do you experience your symptoms?
7. How would you describe the pain?
8. How are your symptoms changing with time?
10. Who else have you seen for your problem?
11. Do you consider this problem to be severe?
14. What is your:
15. How would you rate your overall Health?
16. What type of exercise do you do?
17. What is your daily intake of the following?
18. Indicate if you have any immediate family members with any of the following:
19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.
24. What activities do you do at work?
26. What concerns you the most about your problem?
27. How much has the problem interfered with your work?
44. Check ALL areas of treatment that interest you:
45. Did you know that all treatments above are 100% safe?
46. Have you ever used any of the above treatments before?
47. What do you consider to be your ideal weight?
48. How much weight do you want to lose?
49. When was the last time you were at your goal weight?
50. How many times a year do you diet?
51. What is stopping you from losing weight on your own?
52. What have you tried in the past that has failed?
53. Does your weight problem make you physically uncomfortable?
54. Does your weight problem cause physical pain?
55. Are you embarrassed by your excessive weight?
56. Does being overweight and unhealthy limit your activities?
57. Do you binge eat
58. Do you suffer from uncontrollable cravings?
59. Do you feel that food controls you?
60. Do you eat because of your emotions?
61. Do you eat between meals?
62. What do you choose to eat between meals?
63. Do you feel that your eating behaviors are normal?
64. Briefly describe your daily eating behaviors:
65. Do you feel tired, run-down, or out of energy?
66. Is successful weight loss a top priority?
67. How fast do you want to be slim, trim, and fit?
68. What's more important to you: fast or permanent?
69. Does your family support your weight loss efforts?
70. Is your family excited that you're working with us?
71. Can you remember being at your ideal weight?
72. What do you remember most about it?
Check the following conditions you would like help with or more information on:
What is the most important element in deciding to use our services?
Do you have a Secondary Insurance?
Are you enrolled in a
Credit/Debit Card Information: (please print legibly)
Assignment and Release (insured patients)
Consent to Care
NOTE: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our office.