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:
Hm Phone: 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?
Circle 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.