| Blood Pressure:
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| Name:*
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| Address:
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| City:
State:
Zip:
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| Home phone:*
Work phone:
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| E-mail:*
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| Age: Gender:
Height:
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Weight:
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Program of Interest:
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How did you learn about Body Makeovers?:
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Weight Loss Goals and History |
| How much weight do you want to lose?
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| What would you consider your ideal weight to be?
lbs. |
In your own words, would you describe your body as:
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Do you gain weight easily?
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Do you lose weight easily?
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What diets have you tried in the past?
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Do you usually regain the weight you have lost on a diet?
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How long have you kept the weight off, after having lost it?
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Do other members of your family have a weight problem?
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When did you start to gain weight?
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Have you always had a weight problem?
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Do you feel "over-full" or uncomfortable after meals?
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Do you monitor your cholesterol level?
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| Eating Habits |
Check if you eat, drink, or use:
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Describe your daily water intake:
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Do you drinith meals?
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What other liquids do you drink regularly?
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Do you drink 5 or more cups of caffeinated beverages per day?
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Do you monitor your salt intake?
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How many times do you eat each day (including snacks)?
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When do you eat your meals?
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When do you start eating during the day?
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| Is it a meal or a snack?
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When do you usually eat your last meal?
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What do you normally eat for breakfast?
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What do you normally eat for lunch?
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What do you normally eat for dinner?
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Are you hungry shortly after you eat?
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Do you get sleepy during the day?
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When?
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When do you experience peak energy levels?
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Do you get up frequently at night to urinate?
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Do you ever get shaky?
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Are you Hypoglycemic?
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Do you get headaches?
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Do you have dizzy spells?
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Do you eat carbohydrates before working out?
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Do you eat protein after working out?
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What foods do you crave?
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Do you use condiments?
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Are you a compulsive eater?
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Do you starve all day and binge at night?
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Do you have to eat out frequently for business reasons?
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Do you eat when you are:
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How would you rate your metabolism?
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Do you fixate on food?
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Are you a strict vegetarian?
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Do you eat red meat?
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Do you eat chicken?
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Do you eat fish?
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Do you celebrate with food?
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Do you think of food as a reward?
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Are you allergic to any of the following foods?
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Circle the number which best describes the intensity of your symptoms.
0=Symptom is not present 1=Mild 2=Moderate 3=Severe |
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1) Burping
2) Bloating
3) Constipation
4) Upset stomach
5) Hard stool
6) Abdominal cramps
7) Indigestion
8) Poor appetite
9) Pain in right side under rib cage
10) Pain in left side under rib cage
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List everything you have eaten, as best as you can remember, in the past two days including snacks and beverages.
Accuracy and completeness are essential. Don't worry, we won't tell anyone! |
Yesterday
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Day before
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| Exercise Habits |
How often do you exercise? (40 minutes of aerobic activity, i.e., walking, jogging, bicycling, swimming, etc.)
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What time do you usually do your aerobic (cardiovascular) activity?
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What time do you usually work out?
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Do you stretch before working out?
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Do you own any exercise equipment?
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Do you incorporate weights (resistance equipment) into your workout routine?
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What is your daily activity level?
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what is your work schedule?
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Can't tolerate much exercise?
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| Medical Information
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| Medical History |
Check all that apply:
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Indicate any medication that you are taking:
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Identify any serious injuries you have sustained or operations you have had in the past ten years:
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This is not a casting for Extreme Makeover. Thank you.
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| Body Makeover Systems Inc. Copyright © 2008 All Rights Reserved |
