WEIGHT LOSS REGISTRATION FORM
To assist us with the preview of your personal information and expedite the consultation, please complete this registration form.
Your success is our #1 priority. Assist us in helping you to attain that success by filling out this questionnaire as completely as possible.
This information will be kept
strictly confidential
.
Date:
Name:
Marital Status:
Address:
City/State/Zip:
DOB:
Age:
Occupation:
Phones/Contact:
Home:
Work:
Cell:
Email:
Method of Payment:
Cash
Check
VISA
MasterCard
Driver's License #
(if paying by check):
State:
Have you ever seen a
(check all that apply)
Psychologist
Counselor
If yes, please give their name(s):
Where did you hear about us?
(check all that apply)
Newspaper
TV
Yellow Pages
Radio
Physicial Referral
Web Site
Other
(specify)
How were you referred to Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location
(City/State/Zip)
:
Do you object to us contacting him or her about your success?
Yes
No
What worries you most about weight gain?
How long have you been overweight?
How much weight have you decided to lose?
How many times have you failed at weight loss?
Do you have any of these problem behaviors which we might solve easily & quickly through counseling? (Check all that apply)
Smoking
Pain Management
Sexual Dysfunction
Depression/Anxiety
Excessive Drinking
Anger
Nail Biting
Phobias/Fears
Insomnia
Stress
Break-ups
Improve Memory
Give three reasons why you believe you are overweight?
1.
2.
3.
Please indicate the foods being consumed too much or at least once a week. Check ALL that apply.
JUNK/FAST FOODS
Hamburgers
French Fries
Potato Chips
Pizza
Salty Snacks
Fried Foods
Pork
SWEETS
Donuts
Cakes
Pies
Desserts
Chocolate
Pancakes
Cookies
Candy
STARCHES
Potatoes
Spaghetti
Macaroni
Bread
Biscuits
Rolls
Rice
Pastas
DAIRY
Ice Cream
Milk Shakes
Whole Milk
Butter
Cheese
CAFFEINE
Sweet Tea
Soft Drinks
Coffee
Please indicate any other foods that may not be listed:
Do you need to reduce large portions?
Yes
No
Do you need to increase water intake?
Yes
No
Do you need to increase vegetables & fruit?
Yes
No
Do you need to decrease alcohol?
Yes
No
Indicate whether these are problem behaviors for you:
Late Night Eating
Self and others sabotaging weight
loss
Rapid Eating
Snacking frequently
Eating out of boredom, stress, depression
Lack of exercise
What is your current weight?
What is your goal weight?
Do you have diabetes/hypertension or other unhealthy food related disorders?
Yes
No
If yes, please indicate:
Are you taking medication that causes weight gain?
Yes
No
Have you ever experienced a seizure?
Yes
No
Does your weight problem make you physically uncomfortable?
Yes
No
Explain:
Does being over weight limit your activities and social life?
Yes
No
Explain:
How many times a year do you diet?
Do you feel out of control or suffer from uncontrollable cravings?
Yes
No
Explain:
Do you eat because of emotions or when you are not hungry?
Yes
No
Explain:
Has being overweight caused you pain and
suffering? (Describe physical and/or emotional pain)
Are you embarrassed about your weight?
Yes
No
Explain:
Briefly describe your eating behavior.
Do you believe weight loss has to be painful?
Yes
No
Do you believe weight loss can be enjoyable?
Yes
No
How soon do you want to be trim and fit?
Do you feel your eating behavior is normal?
Yes
No
Do you feel tired, run down and out of energy?
Yes
No
Have you successfully lost 20 lbs or more in the past?
Yes
No
If so, how did you do it?
How serious are you about taking care of your weight problem? Circle your strongest desire, with 10 equaling the strongest.
1
2
3
4
5
6
7
8
9
10
For Smokers Only
How many cigarettes (packs) per day?
Number of years smoking?
Select the strongest desire to stop smoking, with 10 equaling the strongest.
1
2
3
4
5
6
7
8
9
10
List three places or situations in which you smoke the most:
1.
2.
3.
Please submit and bring in this form to your consultation.