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