Weight Loss Management Intake Form

Full Name

First

Last

Date of Birth

Email Address

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Current Weight (kg)

Weight Expectations on

Target Weight (kg)

Height (in inches)

Medical Conditions or Medications

Weight Loss Goals and Expectations

Do you have any of the following conditions? (Check all that apply)

List any other health condition, if applicable

Are you currently pregnant or breastfeeding?

Do you have a history of:

Cancer type and year

Do you consume alcohol?

If yes, how often?

Do you use tobacco or vape?

How would you describe your dietary habits?

Do you exercise?

If yes, how many days per week and what type of exercise?

How many hours of sleep do you get on average per night?

Do you feel rested?

Consent to Participate

I consent to participate in the weight loss management program.
I confirm that the above information is accurate to the best of my knowledge.
I understand this form is used for evaluation purposes only and does not guarantee treatment.

Date