The following health and weight history is required in order to properly access your eligibility for our weight loss program. Should you become a client, it will help establish your needs and limitations during the program. Therefore it is extremely important that you answer all questions as accurately and thoroughly as possible to place you on the correct diet for your medical situation as well as to prevent any possible herbal and drug interactions. All information given will be kept private and confidential.
 

  ABOUT YOU
      * REQUIRED INPUT
 
* First Name: * Last Name:
* Address: * City:
* State:   * Primary Phone 
 * Zip: Cell Phone:
    Alt Phone:
Birthday:
MM  DD YY
Occupation:
Spouse Name: * Email:
* Best Time To Call: 
 
 

  WEIGHT LOSS HISTORY
 
Present Weight: Goal Weight: Difference:
How Did You Hear About Our Program?:

* Has Your MD Recommended That You Lose Weight?:   
How Long Have You Been Overweight?:
Is There Anyone Else In Your Family Who Is Overweight? If Yes, Please List:

Ways You Have Tried To Lose Weight?:

Why Is It Important For You To Lose Weight Now: (check all that apply)
Health Appearance Doctor Recommends
Need More Energy Self Esteem To Please Mate
Look Better in Clothes To Be Able to Exercise  
Upcoming Event:

Event: Event Date:
 
 

  MEDICAL HISTORY
 
Your Primary Care Physician:
Date of Last Exam:
Are You Seeing Other Doctors?
If Yes, Please List Other Doctors:
* Are You Currently Under Physicians Care?:  
If Yes, What For?:
List All Current  Medications:
Are Any Allergy Medications?: (name them)
List All Vitamins & Herbs You Are Taking:
* Do You Drink Coffee?:
* Do You Take Over The Counter Stimulants?:
* Are You A Vegetarian?:
List Any Diet Restrictions:
* Do You Have Any Food Allergies?:
If Yes To Food Allergies, Please List:
* Are You Allergic to Iodine?:
* Are You Allergic to Shellfish?:
* Are You Allergic to Pineapple?:
 
 
 
 

Please check the following medical conditions that apply to you.  We tailor every program for each individual client based on this information; therefore, it is imperative that you disclose everything listed.

Check Any Conditions That Apply To You:

SECTION I
Angina Pectoris (w/Nitro) Cancer (last 12 months) Epilepsy (uncontrolled)
AIDS or HIV + Liver Disease Kidney
Multiple Sclerosis Major Surgery (last 3 mo.) Blood Disorder
Pregnant or Breast Feeding Anorexia/Bulemia (now) Intestinal Disorders
Gastric Bypass (ever)   Are You Taking Any Of These Medications:
Lithium Marplan Norpramine
Resperidol Depakote Phenabarbitol
Nardil    

Have You Been Diagnosed with Hepatitis?

SECTION II

Irritable Bowel/Spastic Colon   (diagnosed)

 Gallbladder Disease
       (last 3 Mo)		 Anorexia/Bulemia (past)

Heart Attack or Stroke

Only One Kidney

Auto-Immune Disorder

Blood Clots

Ulcer (last 12 weeks)

Active Alcoholic

High Blood Pressure
      (only if taking 3 or more BP meds, not diuretics)

Stomach Surgery
     (More Than 2 Yrs Ago)

Suicidally Depressed
     (under treatment for)

Cancer - Other than Skin
     (inactive over 1 year)

Diabetes Type I Insulin

Diabetes Type II Oral

SECTION III
Chronic Constipation Cortisone Therapy Lactose Intolerant
Hypoglycemia Inactive Ulcer Hypothyroidism
Hyperthyroidism Kidney Stones Hiatal Hernia
High Blood Pressure (1-2 Med) Glaucoma Controlled Epilepsy
Gout Taking Diuretics Frequent Urination
Irregular Heartbeat Pacemaker Stomach Surgery
      (Within Last 2 Years)
High Cholesterol Cancer (last 12 months)        ulcer   stapled

Taking Any Mood Altering Drugs
Please List:
     
 

My responses are true to the best of my knowledge. I understand that the BEFORE & AFTER WEIGHT LOSS CLINIC will not provide medical treatment and that it is up to me to consult my physician before beginning any weight loss program, as it can affect my need for medications I may be taking or conditions that I may have. I agree to inform this clinic of any changes in my health, physical condition, and medications. I desire to start this weight loss program, and I take full responsibility for my action and do not hold BEFORE & AFTER WEIGHT LOSS CLINIC responsible in any way.

*REQUIRED AGREE TO TERMS OF SERVICE? 

       

 If you do not hear from us within 48 hrs, please call the local or toll free number
for your local area clinic which can be found on our contact page.