Fields marked with * are required. When you have
completed filling out the form, click the SUBMIT
button to proceed.
*First Name:
Name you prefer:
*Address:
*City:
*Home Phone:
Cell Phone:
*Email address:
*Date of birth:
*Gender:
Please Select
Male
Female
Marital Status:
Please Select
married
divorced
single
widowed
living with a partner
Employment Information
Employer:
Employer Address:
City:
Work Phone:
In Case of Emergency
Name:
Relationship:
Spouse:
Family Physician:
*How did you hear about us?
Please Select
Current Patient
Search Engine
Chat Room
TV Commercial
Print Ad
Brochure
Friend/Word of Mouth
Other
Medical History
Are you in good health at present?
Are you currently under a doctor's care?
If yes, what for?
*List any medications
you are taking: (if none, enter n/a)
*List any medications you are allergic
to:
(if none, enter n/a)
Check any that you
have a history of:
Describe improvements you would
like to see in your health:
Past medical history: (Check all that apply)
Family history:
Father
Mother
Brothers
Sisters
Has any blood relative
had any of the following:
Lifestyle Evaluation
*Present weight:
When would you like to reach
your target weight?
Weight at 20 yrs old:
Weight 1 yr ago:
When did you begin to gain
weight?
Please Select
After Childbirth
After Marriage
After employment change
During stressful time
Other
How long have you been overweight?
Please Select
1 year or less
2 - 5 years
6 - 10 years
> 10 years
What do you feel is the reason
for your weight problem?
Please Select
Frequent overeating
Fattening foods
Lack of exercise
Heredity
Other
How long have you been able
to stick to a diet?
Please Select
0 - 1 month
2 - 6 months
7 - 12 months
Over 12 months
What other weight reduction
methods have you tried?
Please Select
Weight Watchers
Other diet centers
Physicians
Do it yourself
Other
Why did you drop out of diets
before?
Please Select
boredom
hunger
stress
needed assistance
other
What is the nature of your
difficulties while dieting?
Have you been advised by your
physician to lose weight?
List any physical problems
that you know are associated with your weight:
Why do you want to lose weight?
Please Select
social reasons
appearance
special occasion
health reasons
to please family/friends
other
Has your spouse/partner encouraged
you to lose weight?
Explain:
How important is it to you
to lose weight?
Please Select
extremely important
important
not very important
Is your spouse/partner overweight?
Employment status:
Please Select
full time
part time
do not work outside home
Your worst food habits:
Your snack habits:
Your typical breakfast:
Your typical lunch:
Your typical dinner:
Your typical energy level:
Activity level:
Financial
Policy
Thank you for selecting Scale Solutions for your
health care needs. We are honored to be of service
to you. This is to inform you of our billing requirements
and our financial policy. Please be advised that
payment for all services and products will be due
at the time services are rendered, unless prior arrangements
have been made. For your convenience, we accept Visa,
MasterCard, and cash.
*
*
Patient
Informed Consent for Appetite Supressants & Supplements and
have agreed to the terms.
*Enter full name (e-signature):
