Body Sculpting Program Intake Form

Date

First Name

Last Name

Date of Birth

Gender

Male Female Prefer not to disclose

Phone

Address

City

State

Zip

Marital Status

Single Married Divorced Widowed

Number of people in household:

Number of kids in household:

Primary emotional support person (Ie: self / spouse / parent / other)

Please describe any current major stresses

Medical History

You consider your health to be:

Good Fair Poor

Please describe any health conditions checked.

Please list any medications/supplements you take, what you take them for and how often you take them:

Please list any food allergies you may have and the reaction you had

Please list any health care visits you have had in the past 12 months and what you were being seen for.

Body/Exercise

Please list your current height and weight

Goal Weight

Body fat%

RMR

Please list 3 health and fitness goals.

Please describe any previous weight loss experiences, successes, failures, programs, etc

What would you identify as your biggest obstacles to achieving your goals?

Do you exercise?

Yes No

If you exercise, how long ago did you start? (days/months/years ago)

Number of minutes you exercise per time

How many times per week do you exercise?

Please describe any physical limitations?

If your weight has changed in past 6 months, how many pounds has it gone up or down?

Nutrition

If you are following any diet, what type?

You vary what you eat. Please indicate which meals you eat/drink on a typical day.

Do you skip meals?

Yes No Sometimes

How often do you eat out and what restaurants? ( daily / weekly / monthly)

Do you currently have problems with chewing?

Yes No

Do you currently have problems with swallowing?

Yes No

Do you currently have a lack of appetite or overeating:

Yes No

Caffeine per day

None 1-2 Servings 3-4 Servings 5+ Servings

Alcohol per week

None 1-2 Servings 3-4 Servings 5+ Servings

Do you use tobacco?

Yes No

Personal Goals

My long term weight goal is to: (decrease number of lbs or increase number of lbs, or maintain weight)

Please list 2 other personal health goals:

Make changes in my diet. To meet this goal I will

Increase my Physical activity. To meet this goal I will

Diabetes Assessment

If you do NOT have diabetes skip this section.

Do you have Diabetes?

Yes No I have pre-diabetes

Type of diabetes:

Type 1 Type 2 Don’t know

What do you hope to learn about diabetes?

Diet Blood sugar monitoring Other

Please describe any diabetic problems checked

Do you take diabetes medication?

Yes No

Do you test your Blood sugar?

Yes No

Do you have glucose over 200?

Yes No

Do you have glucose below 70?

Yes No

Do you test urine for ketones?

Yes No

Which ketones ones / How often

Most recent fasting glucose: (2 hrs post meals)

Are there any financial concerns affecting diabetes care?

Are there any religious practices/restrictions affecting diabetes care?

Any other information

Certification of Information

By clicking, this box and entering my name is the signature field below, I certify that the above information supplied by me is true and complete to the best of my knowledge. The above information will be reassessed with each patient follow up visit. Changes will be noted on “Follow up sheet”.

Patient Name (signature)

Body Sculpting Program Intake Form – Rockford, IL