Before and After Weight Loss Clinic

The following health and weight history is required in order to properly access your eligibility for our weight loss program. Should you become a client, it will help establish your needs and limitations during the program. Therefore it is extremely important that you answer all questions as accurately and thoroughly as possible to place you on the correct diet for your medical situation as well as to prevent any possible herbal and drug interactions.

ATTENTION: Due to technical complications, several Health Profiles were never received. If you have filled out this form in the past month, please call 1-888-657-5042. We apologize for any inconvenience.

*Required fields

*Your Full Name:

Birthday:

*E-mail address:

Phone:

Business Phone:

Street Address:

City:

State:

Zip/Postal code:

Occupation:

Spouse's Name:

WEIGHT LOSS HISTORY

Present Weight:

Goal Weight:

Difference:

How did you hear about our program?

Has your physician remommended that you lose weight?
Yes No

How long overweight?

Do you have a family member who is also overweight?
Yes No

Who?

Other ways you have tried to reduce:

Why is it important for you to lose weight now?
(check all that apply)

Health

Appearance

Doctor Recommends

Need more energy

Self Esteem

Please mate

Look better in clothes

To be able to exercise

Upcoming Event

Event: Date of event:

HEALTH HISTORY

Family Physician:

Date of Last Exam:

Other Doctors:

Are you currently under a physician's care?
Yes No

For?

List all medications you are currently taking:

Are any of these allergy medications? (name them)

List all vitamins and herbs you are currently taking:

Do you drink coffee?
Yes No

Do you take any over-the-counter stimulants?
Yes No

Are you a vegetarian?
Yes No

Other diet restrictions:

Do you have food allergies?
Yes No

To what?

Are you allergic to iodine?
Yes No

Are you allergic to shell fish?
Yes No

Are you allergic to pineapple?
Yes No

MEDICAL HISTORY

Please check the following medical conditions that apply to you. We tailor every program for each individual client based on this information; therefore, it is imperative that you disclose everything listed.

Check any condition that applies to you

SECTION I

ANGINA PECTORIS
(Relieved with Nitro)

CANCER
(in last 12 months)

EPILEPSY
(uncontrolled)

AIDS or HIV POSITIVE

LIVER DISEASE
(Cirrhosis, Hepatitis)

KIDNEY
(failure; dialysis)

MULTIPLE SCLEROSIS

MAJOR SURGERY
(in last 3 months)

BLOOD DISORDERS
(Hemophilia, leukemia, or porphyria)

PREGANT or BREAST-FEEDING

ANOREXIA or BULIMIA
(now)

INTESTINAL DISORDERS
(Crohn's Disease, Severe Illeitis, Colostomy or Illeotomy)

GASTRIC BYPASS
(ever)

ARE YOU TAKING ONE OF THESE MEDICATIONS

Lithium	Marplan
Nardil	Norpramine

SECTION II

IRRITABLE BOWEL SYNDROME or SPASTIC COLON
(diagnosed)

GALLBLADDER DISEASE
(last 3 months)

PAST HISTORY OF ANOREXIA OR BULEMIA

HEART ATTACK OR STROKE

ONLY ONE KIDNEY

ACTIVE HEPATITIS
(in last year)

BLOOD CLOTS

ULCER
(in last 12 wks.)

ACTIVE ALCOHOLIC

HIGH BLOOD PRESSURE
(check only if taking 3 or more meds)

STOMACH SURGERY
(within last 2 years)

SUICIDALLY DEPRESSED
(under treatment for)

CANCER - other than skin
(inactive over 1 year)

DIABETES

TYPE I: Insulin

TYPE II: Oral

TAKING ANY MOOD ALTERING DRUG

List them:

SECTION III

CHRONIC CONSTIPATION

CORTISONE THERAPY

LACTOSE INTOLERANCE

HYPOGLYCEMIA

INACTIVE ULCER

HYPOTHYROIDISM

KIDNEY STONES

HIATAL HERNIA

HYPERTHYROIDISM

HIGH BLOOD PRESSURE
(1-2 meds)

GLAUCOMA

CONTROLLED EPILEPSY

GOUT

ON DIURETICS

FREQUENT URINATION

IRREGULAR HEARTBEAT
pacemaker

STOMACH SURGERY
(over 2 years)

ulcer

stapled

HIGH CHOLESTEROL

CANCER
(in last 12 months)

My responses are true to the best of my knowledge. I understand that the BEFORE & AFTER WEIGHT LOSS CLINIC will not provide medical treatment and that it is up to me to consult my physician before beginning any weight loss program, as it can affect my need for medications I may be taking or conditions that I may have. I agree to inform this clinic of any changes in my health, physical condition, and medications. I desire to start this weight loss program, and I take full responsibility for my action and do not hold BEFORE & AFTER WEIGHT LOSS CLINIC responsible in any way.