New Patient Information Date: ______/______/_____ Name_______________________________________________ Date of Birth ____/____/______ Age _____ Your Address___________________________________________________________________________ City ___________________________ State _________________________ Zip ___________ Home Phone ______­______­______ Cell ______­______­_______ Work ______­______­_______ Email Address ________________________________________________________
Primary Physician ________________________________________ Phone #______­______­_______ Occupation: _____________________________ Employer name __________________________ Shift Worked: (Day/PM/Night) Height _________ Current weight_________ Goal weight ___________ Age last at goal weight _______ Lifetime heaviest (non­pregnant) ___________ Age at Heaviest ___________ Have you ever had bulimia, anorexia or binge eating disorder ____________________________ Do you smoke ___ If yes how much/day _____ How many years ___ Alcoholic Bev/week:_______ How did you hear about CoreLife?_________________________________________________ Is there something specific that is motivating you?______________________________________________ List any other weight loss programs in past? The main reason you have been unable to lose weight, in your opinion, is... WOMEN: Are You Pregnant _________ Are you breastfeeding _________ Are you menopausal or premenopausal _________________________________ MEDICAL When was the last time you spoke to a Physician about your weight?_______________________
Do you crave food often? (Y / N) Do you find that you have low energy? (Y / N) Are you interested in a prescription medication to help increase your metabolism? (Y / N) Do you consume a multivitamin? (Y / N) Have you had any serious illness in the past that has led to hospitalization (Y/N) Please Explain _______________________________________________________________________ Have you had any surgeries (Y / N) If yes, please explain _________________________________________ ​
Please circle if you have been having any of the following symptoms Weakness
Thick tongue Swollen feet
Swelling of face & eyelids Dry, Coarse skin
Coarse hair
Hoarseness Excessive/painful menses Tired/fatigue Pale skin Loss of appetite Emotional instability Slow speech
Constipation Poor memory Depression Slow movement Gain in weight
Nervousness Brittle nails Coldness and cold skin Loss of hair
Heart palpitations Diminished sweating Headaches Difficulty breathing Other symptoms _____________________________________________________________________ Please check the medical conditions that YOU have been diagnosed with in the past or currently ❏ Past or current drug or alcohol problems ❏ Depression or anxiety ❏ Diabetes: Type 1(juvenile) or 2(adult) ❏ Gestational Diabetes ❏ Insulin Resistance/Prediabetes/BorderlineDiabetes/Dysmetabolic Syndrome ❏ Polycystic Ovarian Syndrome ❏ Heart Burn ❏ Glaucoma (Open or Narrow Angle) ❏ High Cholesterol ❏ High Blood Pressure ❏ Heart Disease/Heart Attack/Heart Failur ❏ Arrhythmia ❏ Heart Valve Problems/ Heart Murmur ❏ Do you have a pacemaker: yes or no ❏ Do you have a defibrillator: yes or no ❏ History of passing out (syncope) ❏ Asthma or other Lung diseases (Type: _______________________) ❏ ADHD (Attention deficit disorder) ❏ Bipolarism or other psychiatric conditions (Explain: _______________) ❏ Kidney Disease (Type: _______________________) ❏ Liver Disease (Type: _______________________) ❏ Obstructive sleep apnea (use a CPAP) ❏ Insomnia/ other sleep disorders ❏ Thyroid Disorders (Low or High or Other: _______________________ ❏ Other Chronic Medical Conditions: _______________________ ❏ Do you have any known Drug allergies? If yes please explain:______________________________ Current Medication and Dose:
Over the counter Medication and Dose: 1)__________________________________ 1)__________________________________ 2)__________________________________ 2)__________________________________ 3)__________________________________ 3)__________________________________ 4)__________________________________ 4)__________________________________ 5)__________________________________ 5)__________________________________ 6)__________________________________ 6)__________________________________ 7)__________________________________ 7)__________________________________ 8)__________________________________ 8)__________________________________ 9)__________________________________ 9)__________________________________ 10)_________________________________ 10)_________________________________ Other Comments:__________________________________________________________ WHO in your FAMILY has had the following? (mom, dad, siblings, aunts/uncles, cousins, grandparents) Heart disease/Heart Attack/Congestive Heart Failure
_____________________ Cancer (list type)
____________________________________ High Cholesterol
____________________________________ Sudden Death ____________________________________ Diabetes or borderline diabetes ____________________________________ Mental illness (depression, bipolar, etc.) ____________________________________ Who in family struggles with weight
____________________________________ Hypothyroidism ____________________________________ Stroke ____________________________________ High Blood Pressure
____________________________________ Other medical condition ____________________________________ NUTRITION FOOD ALLERGIES/SENSITIVITIES (please check those that apply) __Cocoa __Milk Protein __Corn __Soy __Eggs __Gluten __MSG __Lactose __Other: _______ __Vegetarian Are you interested in a structured meal plan that told you exactly what to eat every day? (Y / N) Have you seen a Dietitian? (Y / N) Has your weight fluctuated and you don’t know why? (Y / N) Drink alcohol? Y/N How often? ______________ Smoke? Y/N How much? ____________ __Aspartame EXERCISE Has a trainer ever evaluated you? (Y / N) Are you interested in speaking with a trainer about what’s best you for your strength, aerobics, flexibility, etc? ( Y/ N) Do you Exercise daily? Y/N What and how often? ________________________________________ Does anything limit you from being physically active? __________________ Available Times for Training:
M T W T F S S AM or PM Are you looking for a place that is convenient & comfortable to exercise in on your own time? (Y / N) LIFESTYLE Which of the following seem to sabotage your weight loss efforts (circle those that apply): • Lack of time for planning & self
• Liquid calories such as alcohol • Comfort/stress eating
• Specific food cravings like carbohydrates • Enjoyment of food
• Mindless eating/Habit • Social Events
• Always hungry • Eating late/waking up eating • Boredom eating How quickly are you expecting to lose the weight? What are you most interested in at CoreLife? Is there anything else we should know? Please check all those that apply: I eat large portions, get second, or overfill my plate I eat too quickly, chew foods poorly or take too large of bites I skip meals or go for longer than 5 hours between meals I am an emotional eater or I eat more when I am stressed I dine out (carry­in) more than 3x a week I drink less than 8 cups of water daily I frequently eat fried, fast, and high fat foods I gulp (rather than sip) my beverages or drink too quickly I frequently eat sweets and desserts I drink beverages with calories (juice, punch, soda, etc) I graze (snack all day long) while doing other things I usually drink more than 2 carbonated drinks daily I eat high calorie snacks I usually drink more than 2 cups of coffee or caffeine daily I wake up & eat during the middle of the night I usually drink 2+ alcoholic beverages daily I don’t eat enough protein (less than 4­ 6 oz of meat, fish, poultry per day) I have a relative or friend who may try to hinder my weight loss efforts In the past I have not been good about taking vitamins and/or medications I rely on someone else to purchase and/or prepare my food My calorie intake is low (below 1000 calories/ day) I have a difficult work schedule I never feel full even when I eat a lot I am addicted to food I would have a difficult time giving up: _____________ Other: Describe your usual daily eating pattern: Time Meal Foods and Beverages Breakfast Snack Lunch Snack Dinner Snack Please list any dislikes you may have