Medical Weight Loss Program - Intake Form | Next Level Health in Township NJ

Name(Required)

First Last

Address(Required)

Please input your Street Address

City(Required)

State(Required)

Zip Code(Required)

Email(Required)

Phone Number(Required)

Birthdate:(Required)

MM slash DD slash YYYY

Age(Required)

Sex(Required)

Male

Female

Height:(Required)

Weight(Required)

Occupation(Required)

In Case of Emergency:

Name(Required)

First Last

Relationship(Required)

Phone Number(Required)

How did you hear about us?(Required)

Are you under the care of a qualified healthcare professional? Please list whom.(Required)

As detailed in the Consent portion, it is highly recommended that you are under the care of a qualified healthcare professional, who has verified that it is safe for you to exercise and be on a weight loss program and is monitoring medications and any health concerns that you list here (besides your weight issues- that’s what we’re covering). If you are on medications (particularly for high blood pressure, heart issues, or diabetes), you will need these to be monitored during and after the program as your need for them may change.(Required)

*I acknowledge the above statement above. Please use your mouse to click and draw your signature in the box below if you're on a computer. If you're on a mobile device, simply use your finger to sign.

Please Enter Today's Date(Required)

MM slash DD slash YYYY

Medical History

Please list any medical conditions a medical provider has diagnosed you with in the past (such as high blood pressure, diabetes, arthritis, etc…):(Required)

What medications, supplements and over the counter items do you take regularly or are currently prescribed: *(Required)

Any past surgeries and hospitalizations? *(Required)

Please describe your family history in terms of heart disease, diabetes, obesity, high cholesterol, high blood pressure, and cancer:(Required)

Personal History

How would you describe your stress level?(Required)

How do you manage stress?(Required)

What are your sources of stress?(Required)

Do you have people close to you who support you?(Required)

Diet & Lifestyle

Do you regularly drink alcoholic beverages?(Required)

If yes, how many per week?(Required)

Do you smoke tobacco?(Required)

Do you use recreational drugs?(Required)

What was your highest weight? (excluding pregnancy)(Required)

What was your lowest weight?(Required)

Have you ever stayed the same weight for 10 years or more?(Required)

Factors Contributing to Current Weight(Required)

Please list the factors you feel have contributed to your current weight (check all that apply):

Slow metabolism

Family history of obesity

Comfort food dependency

Lack of exercise

Binge eating

Late night snacking

History of trauma

History of grief and loss

Medication related weight gain

Significant restrictive eating behaviors like anorexia

Health History

Please answer the following questions to the best of your knowledge:

Fatigue(Required)

No, never

Yes, currently

Not currently, but with the last year