PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCell Phone NumberHome Phone NumberEmail *Date of Birth *AgeProfessionMarital StatusSingleMarriedWidowedDivorcedNumber of ChildrenHow did you hear about Better U TodayHeightFeetInchesWeightCurrent WeightlbsHow much do you want to weigh?lbsLowest adult weight?lbsHighest adult weight?lbsHave you been on a diet before?YesNoAt what age did you start trying to lose weight?On a scale of 1 to 10, indicate what level of importance you give to losing weight? *12345678910On a scale of 1 to 10, what level would you rate your stress? *12345678910Please list the factors you feel have contributed to your current weight (check all that apply)?Weight gain following injury or surgeryPregnancyPoor Food ChoicesStress related eatingLack of excerciseSlow MetabolismFamily History of obesityComfort food dependencyEat in isolation due to embarrassmentBinge EatingLate night eatingHistory of traumaCompulsions or cravingsHistory of grief and lossMedication related weight gainMindless eatingSignificant restrictive eating (ex: anorexia)Purging behaviorOtherDaily Eating HabitsDo you eat breakfast every day?YesNoApproximate timeHoursMinutesAMPMExample FoodsDo you eat lunch every day?YesNoApproximate timeHoursMinutesAMPMExample FoodsDo you eat dinner every day?YesNoApproximate timeHoursMinutesAMPMExample FoodsDo you snack between lunch and dinner?YesNoDo you snack between breakfast and lunch?YesNoDo you snack after dinner?YesNoSometimesExample FoodsHow many 8 oz glasses of water do you drink per day?How many 8 oz cups of coffee do you drink per day?Do you drink soda?YesNoDo you drink juice?YesNoDo you drink alcohol?1-3 x per week7-10 x per week2 - 4 x per monthNoDo you have food allergies or intolerances?PeanutsMildModerateSevereWheatMildModerateSevereDairyMildModerateSevereAre you a Vegetarian?YesNoDo you have Celiac Disease?YesNoStrictly Vegan?YesNoPhysical ActivityDo you exercise?YesNoHow many times per week?Type of exerciseDo you belong to a health club or attend classes?YesNoWould you like to change your physical activity/exercise habits?YesNoMedical InformationDo you have diabetes?YesNo (skip to next section)Which type:Type I-insulin dependentType II non-insulin dependent (LR)Type II insulin dependent (LR)Are you under the care of a physician?YesNoDo you monitor your blood sugar?YesNoDo you tend to be hypoglycemic?YesNoAre you currently taking medication for high blood pressure?YesNo (skip to next section)Has your physician restricted your salt intake?YesNoDo you have a pace maker?YesNoHave you ever had any of the following cardiovascular conditions?Blood ClotPulmonary EmbolismHeart Valve Problems/ReplacementArrhythmia/A-fibCoronary Artery DiseaseStroke or TIAHistory of Congestive Heart FailureCurrent Congestive Heart FailureHeart Attack (Please note the year if yes)If you have ever had a heart attack, which year was it?Have you had ANY type of heart surgery?YesNoIf so what type?Date of occurrenceKidney FunctionHave you been diagnosed with kidney disease?YesNoHave you ever had a kidney transplant?YesNoHave you ever had a kidney stone?YesNoHave you ever had gout?YesNoLiver FunctionDo you have liver problems?YesNoIf yes please specify:Colon/Stomach/Digest Function:Have you ever had any of the following?Crohns DiseaseChronic ConstipationDiverticuliisBariatric SurgeryIrritable Bowel SyndromeGastric UlcerChronic DiarrheaOtherIf yes please specify dates and events.Ovarian/Breast Function:Have you ever had any of the following?Irregular, painful or heavy periodsMenopauseEndometriosisAre you pregnant?YesNoAre you breast feeding?YesNoNeurological Function:Do any of these conditions apply to you?Panic AttacksAnxietySchizophreniaAlzheimers DiseaseMigrainesBi-Polar DisorderDepressionEpilepsyParkinson's DiseasePlease list and medications you are taking for these conditions:Inflammatory Conditions:Do any of these conditions apply to you?FibromyalgiaOsteoarthritisChronic Fatigue SyndromeRheumatoid ArthritisLupusMultiple SclerosisOtherCancerDo you have cancer?YesNoIf yes what type and location?Do you have a history of cancer?YesNoIf yes how long have you been in remission?GeneralDo you have any other health problems?YesNoIf yes, please specify:Do you take any vitamins, herbs or supplements on a daily basis?YesNoIf yes, please specify and list the reason for taking:Signature *Start signing your signature hereYour browser does not support e-Signature field.Date *Send Message
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