LifeStyle by Choice  -  Weight Management Intake                        
                                                            (ALL INFORMATION IS CONFIDENTIAL)


NAME                                                                                                  DATE

STREET ADDRESS _____________________________________________ STATE ______     ZIP __________

E-MAIL ADDRESS ___________________________________________________________

HOME PHONE ______ _________________________    CELL PHONE ______ _________________________

I give you permission to contact me via E-mail: YES _____      NO _____ 
 
Via home phone: YES _____     NO _____                Via cell phone: YES _____        NO _____


BIRTHDATE __________________________    FEMALE ______        MALE _____                                
    

Family Status:  I am the _________ child out of _________ children.


My father was/is thin _____, normal weight _____, overweight _____.

 
My mother was/is thin _____, normal weight _____, overweight _____.


1.  My weight goal is _____.  In the past I felt best when I weighed _____.


2.  I began gaining excess weight at age _____.

3.  I was happy with my weight at age _____, or, I was always too heavy _____.
                
4.  The food(s) that seem(s) to put weight on me includes:





5.  The type of exercise I get is _______________________________________________________________ 

            _____________________________________________________________________________________
        
           and I do this __________________________________________________ times a week.

6.   _____________________________________________________________________________ stops me from  
            exercising.

7.   __________________________________________________________________________ stops me from loosing
            weight.

8.  When I eat something I shouldn’t eat my thought(s) right before I eat it are _________________________________
     
           ____________________________________________, and my thoughts when I stop eating are ___________

           ____________________________________________________________________________________________.

9.  I believe that I can loose weight to the point that I am comfortable with myself.

                       YES _____                NO _____


     10.  Five reasons why I want to loose weight are: 
       
           1. ___________________________________________________________________________________________________

           2. ___________________________________________________________________________________________________

           3. ___________________________________________________________________________________________________

           4. ___________________________________________________________________________________________________

           5. ___________________________________________________________________________________________________


FORM: LBC 1002

























   

LifeStyle by Choice
Page 2

Please put an "X" next to any conditions, emotions, or feeling which describes you, or have interfered with your daily
       routine.
This is confidential information.


Nail biting _____                                      *I crave more: before meals _____ or I crave more after meals _____.

Workaholic habits _____                          *I eat even when I know that I am absolutely full _____    

Insomnia _____                                        *I seem to eat more when I encounter personal problems or stress _____
 
Irritability _____                                       *I seem to crave more after eating candy _____ other refined carbs _____

Fatigue _____                                    or  more complex carbohydrates _____
                                                                                         
Restless sleep _____                                *When I crave it is in the morning _____ afternoon ______                             
                                                                     
       Restlessness _____                                        early evening _____ or late at night _____
                                                                                        
       Depression _____                                 
                             
Nervousness _____          

Anxiety _____                                           

Confusion _____                    
         
Desire to drink alcohol _____    
             
Craving of sugar products _____

Craving of fatty products _____

Craving for (add any other here) _____________________________________________________________


I got along with my father all the time _____ sometimes _____ never _____


I got along with my mother all the time _____ sometimes _____ never _____


I was called names during the ages of ____________________________ or, I was never called names _____.


Either my father _____ or mother _____ used alcohol or other drugs in excess.



AGREEMENT

I am willing to be guided through mental and physical relaxation techniques, visual imagery, Clinical Hypnosis, and Neuro-linguistic Programming.  I understand that there are no guarantees for changing human behavior and that the services I purchase from LifeStyle by Choice, LLC are not to be used as a substitute or replacement for professional medical or mental health advice or care. I have read the HIPPA notice of Primary Practices and understand my responsibilities.


SIGNATURE _________________________________________     DATE ________________________________