Application for Weight Loss/Detox Program

    Patient Information

    Please select sex and marital status:

    Health History

    Weight Loss/Detox Questionnaire

    3. Your level of interest in losing weight is (1 = Not Interested | 5 = Very Interested):
    12345

    4. Your level of interest in detoxing your body (1 = Not Interested | 5 = Very Interested):
    12345

    5. Your level of interest in changing your lab work (1 = Not Interested | 5 = Very Interested):
    12345

    8. Please check all previous programs that you have tried in order to lose weight or detox. Indicate dates and length of participation.

    Program

    Date

    Duration (Months)

    Weight Lost

    Weight Watchers

    Overeaters Anonymous

    Liquid Diets

    Diet Pills (Meridia, Xenical)

    Diet Pills (Phen-Fen, Redux)

    Nutrisystem/Jenny Craig

    OTC Diet Pills

    Registered Dietician

    9. Have you maintained any results for up to 1 year at any of these programs?

    11. Do you follow a special diet?

    12. Which meals do you eat regularly?

    13. When do you snack?

    15. How is your food usually prepared?

    16. How many times per day do you have the following items?

    Item

    Times Per Day

    Starch (bread, cereal, pasta, rice, noodles, potatoes)

    Fruit

    Vegetables

    Dairy (milk, yogurt, cheese)

    Meat (fish, poultry, eggs)

    Fat (butter, margarine, mayonnaise, oil, salad dressing, sour cream, cream cheese)

    Sweets (candy, cake, regular soda, juice)

    17. What beverages do you drink daily and how much?

    Drink

    Times or 8 oz. glasses per day

    Water

    Coffee

    Tea

    Soda

    Alcohol

    18. Would you like to change your eating habits?