Intake | Better U Today

Prefix

First Name *

Middle Name

Last Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell Phone Number

Home Phone Number

Email *

Date of Birth *

Age

Profession

Marital StatusSingleMarriedWidowedDivorced

Number of Children

How did you hear about Better U Today

Height

Feet

Inches

Weight

Current Weightlbs

How much do you want to weigh?lbs

Lowest adult weight?lbs

Highest adult weight?lbs

Have you been on a diet before?YesNo

At what age did you start trying to lose weight?

Daily Eating Habits

Do you eat breakfast every day?YesNo

Approximate time

Hours

Minutes

Example Foods

Do you eat lunch every day?YesNo

Approximate time

Hours

Minutes

Example Foods

Do you eat dinner every day?YesNo

Approximate time

Hours

Minutes

Example Foods

Do you snack between lunch and dinner?YesNo

Do you snack between breakfast and lunch?YesNo

Do you snack after dinner?YesNoSometimes

Example Foods

How 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?YesNo

Do you drink juice?YesNo

Do you drink alcohol?1-3 x per week7-10 x per week2 - 4 x per monthNo

Do you have food allergies or intolerances?

PeanutsMildModerateSevere

WheatMildModerateSevere

DairyMildModerateSevere

Are you a Vegetarian?YesNo

Do you have Celiac Disease?YesNo

Strictly Vegan?YesNo

Physical Activity

Do you exercise?YesNo

How many times per week?

Type of exercise

Do you belong to a health club or attend classes?YesNo

Would you like to change your physical activity/exercise habits?YesNo

Medical Information

Do 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?YesNo

Do you monitor your blood sugar?YesNo

Do you tend to be hypoglycemic?YesNo

Are you currently taking medication for high blood pressure?YesNo (skip to next section)

Has your physician restricted your salt intake?YesNo

Do you have a pace maker?YesNo

Have 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?YesNo

If so what type?

Date of occurrence

Kidney Function

Have you been diagnosed with kidney disease?YesNo

Have you ever had a kidney transplant?YesNo

Have you ever had a kidney stone?YesNo

Have you ever had gout?YesNo

Liver Function

Do you have liver problems?YesNo

If yes please specify:

Colon/Stomach/Digest Function:

If yes please specify dates and events.

Ovarian/Breast Function:

Have you ever had any of the following?Irregular, painful or heavy periodsMenopauseEndometriosis

Are you pregnant?YesNo

Are you breast feeding?YesNo

Neurological Function:

Please list and medications you are taking for these conditions:

Inflammatory Conditions:

Cancer

Do you have cancer?YesNo

If yes what type and location?

Do you have a history of cancer?YesNo

If yes how long have you been in remission?

General

Do you have any other health problems?YesNo

If yes, please specify:

Do you take any vitamins, herbs or supplements on a daily basis?YesNo

If yes, please specify and list the reason for taking:

Signature *

Date *