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
7. __________________________________________________________________________ stops me from loosing
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:
FORM: LBC 1002
Please put an "X" next to any conditions, emotions, or feeling which describes you, or have interfered with your daily
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 _____
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 ________________________________