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New Patient Intake Form

Basic Patient Information
Name: _______________________________________________________________ Date: _____________
Street Address: ___________________________________________________________________________
City: _______________________________________ State: ________________ Zip: _________________
Home Phone: _________________________________ Cell Phone: ________________________________
Email Address: ___________________________________________________________________________
Sex: M F Age: ____________ Birth date: ____________ Height: ____________ Weight: ____________
Marital Status: □ Single □ Married □ Widowed □ Separated □ Divorced
Occupation: _________________________________________ Hobby: _____________________________
Who may we thank for referring you? _________________________________________________________
Name of M.D. if currently under care? ________________________________________________________
Medical Prescriptions: _____________________________________________________________________
Has your doctor advised you to lose weight? □ Yes □ No
Do you have any dietary restrictions? □ Yes □ No
Check ALL that apply to you: □ Heart Condition □ Epilepsy/Seizures □ Pregnant □ Might Be Pregnant
□ Taking Heart Medication/Blood Thinners □ Currently Undergoing Chemotherapy □ Breast Feeding
□ Known Adverse Reactions to Niacin or B Vitamins
Health and Wellness History
Please answer the following questions honestly so we can do our best to help you reach your goals.
Check ALL areas of treatment that interest you:
□ Weight Loss □ Cleansing and Detoxification □ Overall Health □ Body Wraps
□ Improving Energy □ Stress Reduction □ Better Sleep □ Other
Did you know that all of the treatments listed above are 100% safe? □ Yes □ No
Have you received treatment for any of the above? □ Yes □ No
When was the last time you were at your goal weight? ___________________________________________
What do you consider your ideal weight? ______________________________________________________
How much weight do you want to lose? _______________________________________________________
How many times a year do you diet? __________________________________________________________
What is stopping you from losing weight all on your own? ________________________________________
What have you tried in the past that has failed? _________________________________________________
Does your weight problem make you physically uncomfortable? □ Yes □ No
Please explain: ___________________________________________________________________________
Does your weight problem cause physical pain? □ Yes □ No
Please explain: ___________________________________________________________________________

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New Patient Intake Form

Health and Wellness History (Continued)
Are you embarrassed by your excessive weight? □ Yes □ No
Please explain: ___________________________________________________________________________
Does being overweight and unhealthy limit your activities? □ Yes □ No
Please explain: ___________________________________________________________________________
Do you binge eat? □ Yes □ No
Do you suffer from uncontrollable cravings? □ Yes □ No
Do you feel food controls you? □ Yes □ No
Do you eat for emotional reasons (stress, anger, sadness, etc.)? □ Yes □ No
Do you eat between meals? □ Yes □ No
What do you choose to eat between meals? ___________________________________________________
Briefly describe your daily eating behavior: _____________________________________________________
Do you feel your eating behavior is normal? □ Yes □ No
Do you feel tired, run down, and out of energy? □ Yes □ No
Is successful weight loss a top priority? □ Yes □ No
How fast do you want to be slim, trim, and fit? __________________________________________________
What’s more important to you fast or permanent? ______________________________________________
Does your family support your weight loss efforts? □ Yes □ No
Is your family excited about you coming here for weight loss? □ Yes □ No
Can you remember being your ideal weight? □ Yes □ No
What do you remember most about it? _______________________________________________________
________________________________________________________________________________________
What is the most important element for you in deciding to use our services?
Circle only ONE of the four answers.
EFFECTIVENESS: “My results are my top priority.”
TIME: “I want results quickly.”
SERVICE: “I need extra support along the way.”
AFFORDABILITY: “What you charge is my concern.”
I understand that my entire patient record will remain completely confidential and will not be
released without express written consent from me.
Signature: _________________________________________________ Date: ________________________