Client History Form for Arizona Location
Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Address
Street Number and Name *
Your answer
Town or City *
Your answer
State *
Your answer
ZIP Code *
Your answer
Do you have Medicare as your primary or secondary insurance? *
How did you hear about us? *
If "other," please specify
Your answer
Referring Person Name
Your answer
Address of Referring Person (if an MD, therapist, or other healthcare provider).
Your answer
Your Age *
Your answer
Height *
Your answer
Current Weight *
Your answer
Overall, how do you feel about your current weight/body? *
Your answer
What is your approximate goal weight? *
Your answer
Highest body weight (non pregnant) and age at that weight? *
Your answer
Lowest adult body weight and age at that weight: *
Your answer
Have you ever been on a diet? *
At what age did you begin dieting?
Over the last year how often have you started a diet?
Your answer
Please indicate the methods you have used to control your weight in the past.
If "other" above, please describe:
Your answer
If you have been on particular diets, e.g., Weight Watchers, paleo, etc., please name them:
Your answer
Are you a member of a sports team, club sport, or a fitness center? *
If yes, which sports team / club sport / fitness center:
Your answer
Please indicate you current regular exercise/activity, include walking: *
(Type of activity, # of times/week, # of minutes/session)
Your answer
Average hours of sleep per night: *
Your answer
Quality of sleep (from 1-10: 1 is worst, 10 is best): *
Your answer
Average number of alcoholic drinks that you drink on each occasion and the number of days/week that you drink: *
Your answer
What did you eat yesterday? (Please be as detailed as you can.) *
Your answer
Is this a typical day? *
If your answer was "no", What do you eat in a typical day?
Your answer
What foods do you avoid?
Your answer
Have you ever had any of the following problems?
Check any/all that apply
If "other" above, please describe:
Your answer
Which of the above have been medically diagnosed?
Your answer
Medications prescribed by doctor, including birth control:
Your answer
Over the counter meds, e.g. diet pills. water pills, laxatives:
Your answer
Please list any supplements you are taking:
Your answer
Please list any food allergies or intolerances (and please let us know if you have done testing for them):
Your answer
Has anyone else in your family had any one of the following problems?
Check any/all that apply
Please list which family members and their medical issues:
Your answer
I eat sweets and carbohydrates without feeling nervous *
I think about dieting *
I feel extremely guilty about overeating *
I am terrified of gaining weight *
I am preoccupied with a desire to be thinner *
I exaggerate or magnify the importance of my weight *
If I gain a pound, I worry that I will keep gaining *
I eat when I am *
Check any/all that apply
Required
It usually takes me this long to eat breakfast *
It usually takes me this long to eat lunch *
It usually takes me this long to eat dinner *
It usually takes me this long to eat snack *
I spend % of the day thinking about food *
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