Weight Loss Program Patient Information Form Page 3
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4When did you begin to gain weight?
⃝ after an employment change
⃝ during a stressful period
⃝ after childbirth
⃝ After marriage
⃝ Other
How long have you been overweight? ⃝ year or less
⃝ 2-5 years
⃝ 6-10 years
⃝ 10 years
What is your cause of your weight problem?
⃝ Frequently overeat
⃝ Enjoy fatting foods
⃝ Lack of activity
⃝ Heredity
⃝ other ___________
How many meals you eat daily? __________________________________________________________
How many serious attempts have you made at dieting? _______________________________________
What is the longest you been able to stick to a diet? ⃝ 0-1 month ⃝ 2-6 months ⃝ 7-12 months ⃝ over 12 months
What other reduction methods have you tried? ⃝ Weight watchers
⃝ Diet Books
⃝ Physician ⃝ Do it yourself
⃝ Other _________________________________________________
What is the nature of your difficulties while dieting? ______________________________________________________
Are you under a physician’s care?
⃝ Yes
⃝ No
Have you been advised by your physician to lose weight?
⃝ Yes
⃝ No
Do you have any physical problems that you know are associated with your weight?
⃝ Yes
⃝ No
Why do you want to lose weight?
⃝ Appearance
⃝ Special Occasion
⃝ Health reasons
⃝ To please family/friends
⃝ Other _______________________________
Has your significant other encourage you to lose weight?
⃝ Yes
⃝ No
How important is it for you to lose weight?
⃝ Extremely important
⃝ Very important
⃝ Important
⃝ Not very important
Do you work? ⃝ Yes
⃝ No
⃝ Full time
⃝ Part time
⃝ Occupation _________________________________
Number of children ____________ Ages _____________________________
Are any of your children overweight? ⃝ Yes
⃝ No
What is your current weight? ___________________What was your highest weight in the last 5 years? ___________
What was your lowers weight in the last 5 years? ___________________What is your goal weight? ______________
Do you have sulfa allergy?
⃝ Yes
⃝ No
Please explain the reason why you want to take the steps necessary to lose weight:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I wish to apply for admission to the Ideal Health Weight Loss Program. I realize that admission cannot be
guaranteed, and will depend on results of a comprehensive medical evaluation I am aware of the financial and time
commitments involved, and feel I can complete the program.
________________________________________
______________________
Signature
Date
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