Client History Form for Vermont 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? *
Are you an employee or student at the University of Vermont? *
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, please list their office address here.
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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