Personal Information Sheet

LIFEWISE WEIGHT MGMT & WELLNESS   CENTER PERSONAL INFO SHEET      Date:___________________

 

Name  ________________________________________  Referral Source_________________________

Mailing address_______________________________________________________________

 

 

E-mail Address__________________Home Phone _____________  Work  ____________Cell  _______________

 

Birthdate_________________            Male_______Female_______

Do you have any of the following health problems: Circle for Yes or Leave blank

 

emphysema                             Anemia: iron/ B12           Bulemia/Anorexia              Thyroid Disease_____________

High Cholesterol                  Diabetes :1 or 2                  Cancer :____________________________________

Gallbladder Disease           Gout                                        Arthritis_____________________________________                       

Hypertension                       Heart Disease                      Gastro. Disorder  ______________________________                                              High Cholesterol Y or N______________

Hypo/Hyper glycemia     IBS_____________       AutoImmune Disease____________________________

Female only: PMS______Flashes/Sweats Y/N     Birth Control Y/N    Hysterectomy: Partial/total      Depo: Y or N

Male: Prostate Issues Y  or N  __________________________

Date of Last blood work:______________Name of Doctor___________________

MEDICATIONS:

 

NATURAL SUPPLEMENTS:

 

Do you exercise?      Y or N                            Days and Times__________________________________________                          ________________________________________________________________________________

What, if any, fitness equipment do you have at home_____________________________________________

Do you smoke? _________If yes, how much?_______________

How much alcohol do you consume per week?______________What:_________________________

How much H2O (water) do you drink per day?Purified______________Tap/city_______________

How much of each of the following do you drink per day, coffee _____ Tea_____ herb tea_____ pop _____d.pop_____

What do you put in your coffee :_____________tea:________________

What methods have you tried to lose weight?______________________________________________

What do you think your ideal weight is?_____________________________

FOR COUNCILLOR USE

 

WEIGHT_____________HEIGHT______________IMPEDANCE______________

 

Info required for program preparation

What time do you get up? (Weekends in Brackets)________ (_____)  Go to bed?_____  (______)

 

Please list time of day you eat 1) breakfast_____ (____) 2)lunch______(_____) 3)supper_____ (____)

 

Your Usual Breakfast_______________________lunch________________________supper_________________

Do you like to bring a lunch to work: Y or N

What times of day do you most regularly snack? (Circle any  that apply)  AM   PM   Evening   All Day

What do you snack on?________________________________________________________

Do you normally overeat at a sitting? (do yo feel your portions are too large)  Y  or    N

How often do your bowels move?_____________________strained or easy

What disease, if any do you have in your immediate family (parents, siblings, grandparents)?

 

Do you work?_______________ If yes what are your hours?__________________________________

How many people live in your household?_______________Their ages?_________________________

Do you do all of the cooking?______________________Do you enjoy cooking?_____________

Circle any of the following that you own:  blender    bullet   crockpot     food processor      juicer     purified water

Please give as much detail in answering the following:

Most Liked Foods        Least Liked or Disliked Foods      Foods I would try       Intolerances or Allergies

 

 

Client Release

While a client with LIFEWISE, I have been forthright about my state of health. It recommended  that I should see my doctor at various weight loss intervals to adjust medications if applicable. This is my responsibility. I do not hold LIFEWISE responsible for any health problems that may occur as a result of my own disregard.

 

Signature___________________________________Date__________________________

Advertisements

Thank You for contacting Lifewise. I will respond to your email as soon as possible.

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s