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Employment Information
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Medical History
Are you in good health at present?
Are you currently under a doctor's care?
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*List any medications
you are taking: (if none, enter n/a)
*List any medications you are allergic
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have a history of:
Describe improvements you would
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Past medical history: (Check all that apply)
Family history:
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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?
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After Childbirth
After Marriage
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During stressful time
Other
How long have you been overweight?
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1 year or less
2 - 5 years
6 - 10 years
> 10 years
What do you feel is the reason
for your weight problem?
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Frequent overeating
Fattening foods
Lack of exercise
Heredity
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How long have you been able
to stick to a diet?
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0 - 1 month
2 - 6 months
7 - 12 months
Over 12 months
What other weight reduction
methods have you tried?
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Weight Watchers
Other diet centers
Physicians
Do it yourself
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Why did you drop out of diets
before?
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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?
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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?
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extremely important
important
not very important
Is your spouse/partner overweight?
Employment status:
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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
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and our financial policy. Please be advised that
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at the time services are rendered, unless prior arrangements
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