Weight Loss Assessment & Consent Form

Before embarking on any weight-loss program please ensure that you have been given a clear bill of health from your medical Doctor or health practitioner. Name: Address: City: Province/State: Country: Postal/Zip Code: Home Phone: Cell Phone: Personal email address: Birth Date (dd/mm/yy): Gender: male female Are you?pregnant nursing Emergency contact: Emergency telephone: What is your height in feet & inches? What is your waist circumference in inches? What is your weight in pounds? What is your target weight in pounds & inches? Have you tried other weight-loss diets or programs in the past? yes no Do you eat for emotional reasons: bored, upset, depressed or anxious? frequently sometimes ocassionally never Do you crave certain foods ( ie: sugar/chocolate/sweets/dessert/potato chips/chesse/breads/pasta )? frequently sometimes occasionally never Do you have a strong sense of life purpose and do you have written goals for everything you want in life? yes no Do you get in 30 min. aerobic exercise ( anything but weight training) at least 3X a week? yes no Do you do at least 20 min of weight lifting twice a week? yes no Do you get adequate sleep ( 7 – 8 hours) every night? yes mostly occasionally never Do you have any health problems besides being overweight? yes no How motivated are you to make to make comprehensive life style changes? very somewhat can't I just take a pill How often do you eat at restaurants & fast food outlets? every day 4-6 x weekly 1-3 x weekly rarely Do you eat processed foods with sugar, high fructose, corn syrup, artifical sweeteners, margarine, polyunsaturated fats, white rice, white flour, juices, MSG, artificial flavors? daily occasionally never Which type of diet program have you tried in the past? Check all that apply. Low-Fat Diet Low-Carb Diet Low-Calorie Diet Weight Watchers Jenny Craig LA Weight-Loss South Beach Diet Curves How often do you feel hunger? 5 x daily 2-4 x a day 1x a day occasionally What is your stress level on a scale from 1-10 (1 = low & 10 = high)? Do you think being held accountable for making lifestyle would be helpful in meeting your goals? yes no How often do you over eat? frequently sometimes occasionally never Do you love yourself & your body the way it is? yes no Do you have trouble in getting up in the morning? yes no Do you run out of energy in the afternoon? yes no Is your armpit resting body temperature below 97.6 on waking before getting out of bed? yes no Do you feel fatigued & sleepy after eating? yes no How many 8 oz glasses of water do you have in a day? 1 2 3 4 5 6 7 8 9 10 How many diet sodas do you drink in a day? 1 2 3 4 5 6 7 8 9 10 How many of the following symptoms do you have? Check all that apply. hair is falling out or thinning a history of Yo -Yo dieting cold hands & feet constipation energy drop in the afternoon voice strain swelling in my throat area utsides of my eyebrows are thinning dry & peeling skin dark skin & patches on my elbows muscle cramps & aches vertical ridges on nails / nails crack & peel more than 20 lbs. over weight skin pigmentation (white patchy areas) head feels tired or heavy trouble staying focused on my job while working not much energy after working 8 hours feel exhausted all the time yellow / thick big toe nails feel dizzy on standing hot flashes short-term memory loss gained weight around my waist in the last year legs jerk while sleeping difficulty losing weight indigestion or burning in stomach after eating allergies frequent cough sensitivity to bright light red eyes frequent headaches confusion poor vision hand tremors impaired memory vertigo retinal disease learning disability bladder irritation joint pain reduced consentration unexplained rash irritable bowel syndrome difficulty driving at night I have the following cravings. Check all that apply. salt chocolate peanit butter cheese banana apples nuts pickles eggs cantaloupe olives onions milk paint/dirt sour / tart fruits hot sauces / spicy foods yes no yes no In the past 2 weeks I have felt: great down depressed or hopeless little interest in doing things I am coping with my stress level: very well can't cope anymore need help Have you had any of the following conditions? Check all that apply. heart attack heart failure high cholesterol high blood pressure bypass surgery cancer stroke chronic pain asthma lung disease arthritis depression frequent headaches diabetes type 1 diabetes type 2 age at diabetic onset use insulin How many surgeries have you had to date? I use tobacco: never I quit What type of tobacco do you use? Check all that apply. cigarettes cigars pipe chewing tobacco If you smoke cigarettes - how many packs a day? My current prescription medications are: I use over-the-counter medications: never occasionally frequently I am ready to make and commit to lifestyle changes to become healthier. no already changing within 6 months longer than 6 months If you were referred by someone, please give us their name & phone # so we may thank them: Weight-Loss Program Consent Waiver: I understand Jeni Shaw or the attending practitioner are not medical doctors nor do they portray themselves to be, but are providing a Weight-Loss Program. I understand that Jeni Shaw or the attending practitioner do not offer allopathic drugs, surgery, chemical stimulants or any other conventional medical treatments. In using the Weight-Loss Program, Jeni Shaw or the attending practitioner do not diagnose, treat, cure or otherwise prescribe for any disease, condition or illness. I have solicited Jeni Shaw’s or attending practitioner's services in good faith, exercising my free will and following the dictates of my own conscience, which allows me to select, what I understand, is most beneficial to my health at this present time. I am fully aware and release Jeni Shaw or the attending practitioner to administer the Weight-Loss Program and that all information disclosed as well as my identity will be held in the strictest confidence except as specifically required by law. By including my name and checking "yes" to the "I consent" option below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask questions with regard to the described programs. I hereby confirm I am not here for medical, diagnostic or treatment procedures and am here on this and any subsequent visits of my own free accord. I presently seek the Weight-Loss Program and or any other programs within the scope of Jeni Shaw or the attending pracrtitioner for the Weight-Loss Program. Name: Date (dd/mm/yy): I consent:yes no

 

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