Weight Loss In-take Form – SoPrecious Lifestyle

SoPrecious Weight Loss In-take Form

First Name

Last Name

Email

Country

Height (inches):

Weight (Kg):

Sex:

Male

Female

Marital Status:

Single

Married

Widowed

Separated

Divorced

Date Of Birth

Occupation:

How did you hear about us?

Facebook

Google

Instagram

Email

Friend

Others

Do you have any dietary restrictions?

Yes

No

Please Explain

How often do you exercise?

What type of exercise?

Do you feel stressed?

Yes

No

Please explain:

Check ALL that apply to you:

Pregnant

Might Be Pregnant

Breast Feeding

Currently Undergoing Chemotherapy

Others

Please answer the following questions honestly so we can do our best to help you reach your goals.

What changed that caused the weight gain (if anything)?

What’s the main reason you are seeking treatment at this time?

What do you consider to be your ideal weight ?

When was the last time you were at your ideal weight?

How much weight do you want to lose?

What is the hardest part about managing your weight?

What have you tried in the past that has failed?

Please check all previous programs that you have tried in order to lose weight.

Weight Watchers

Liquid Diets

Keto Diet

Diet Pills (Phen-Fen)

Nutrisystem/Jenny Craig

Surgery

Low Carb Diet

Have you maintained weight loss for up to a year with any of these programs?

What did NOT work for you about these programs?

What has been your lowest _________ and highest __________ weight as an adult?

What would stop you from a weight loss program?

Do you binge eat?

Yes

No

Do you suffer from uncontrollable cravings?

Yes

No

Do you feel that food controls you?

Yes

No

Do you eat because of your emotions?

Yes

No

Do you eat between meals?

Yes

No

Do you snack between meals ?

Yes

No

Do you feel that your eating behaviors are normal?

Yes

No

Briefly describe your daily eating behaviors:

Can you remember being at your ideal weight?

Yes

No

What do you remember most about it?

Commitment to weight loss: (please rate):

Check the following conditions you would like help with or more information on:

Weight Loss

Thyroid

Knee Arthritis

Memory & Mood

Hormone Balancing

Immune Boosting

Insomnia

Pain Relief

Neuropathy

Joint Pain

Weaning Off Caffeine

Stress Relief

Fatigue

General Wellness

Diabetic Educ.

Fitness

List ALL medications & supplements you take (prescription & over the counter)

Drug Name, Dosage, How long have you taken, & for what conditions?

Please list all known DRUG and FOOD allergies:

Check ALL medical conditions that you may have had or currently have now:

Kindly Specify

Please list all previous surgeries & dates:

Alcohol use?

Yes

No

Specify Amount Daily / Weekly / Socially / None

Tobacco use?

Yes

Never

I fully understand that my signature is consent and authorization to be examined by the Center for Wellbeing
medical team.

I understand that my entire patient history will remain completely confidential and will not be released
without express written consent from me

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