Forney Weight Loss Center
(972) 436-1200
kenny@forneyweightloss.com
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How Its Work
Why it works
Body Contouring
Services
Cryo Facials
Cryo Slimming
Localized Cryo
Medical Weight Loss
Payment Plan
Quiz
Contact
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Intake Form
Intake Form
Home
Intake Form
Patient for Weight Loss Program
Name
(Required)
First
Last
Gender
Male
Female
Marital Status
Single
Married
Single
Divorced
Widowed
Separated
Minor
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Cell
Date of Birth
MM slash DD slash YYYY
Age
School
Spouse/Parent’s Name
City/State
Employer
Whom may we thank for referring you?
Emergency contact
Phone
Physician name
Your Email
(Required)
May we contact you via email?
Yes
No
We will not sell or distribute your email address to any 3rd parties. Email address is used for newsletter and patient communication regarding special events and announcements.
Responsible Party (Other than Self)
Party Name
Patient Relationship
Party Address
Address
City
State
Zip
Party Phone
Health History
Acid Reflux
Anorexia
Bladder
Cancer
Depression
Digestion
Fatigue/Tiredness
Hepatitis
High Cholesterol
Knee Pain
Low Back Pain
Numb/Tingling (Arms/Hands)
Skin
Vision
Allergies
Arthritis
Bowel
Chronic Infections
Diabetes
Dizziness
Headaches
Hernia
Immune
Leg/Hip Pain
Neck Pain
Shoulder/Arm Pain
Stroke
Weight Problems
Bulimia
Concussion
Difficulty Breathing
Elbow/Wrist Pain
Heart Disease
High Blood Pressure
Anemia
Asthma
Kidney Disease
Liver/Gallbladder
Numb/Tingling (Legs/Feet)
Sinus
Thyroid
Weight Loss Questionnaire
1. Is there a reason you are seeking treatment at this time?
2. What are your goals about weight control and management?
3. Your level of interest in losing weight is, (5) being the highest
Interest in losing weight
1
2
3
4
5
4. How much support can your family provide?
No Support
Much Support
5. What’s the hardest part about managing your weight?
6. What has been your lowest and highest body weight as an adult?
7. At what age did you start trying to lose weight?
8. Please check all previous programs that you have tried to lose weight.
Weight Watchers
Overeaters Anonymous
Liquid Diets
Diet Pills (Meridia, Xenical)
Diet Pills (Phen-Fen, Redux)
Nutrisystem/Jenny Craig
OTC Diet Pills
Registered Dietician
Obesity Surgery
9. Have you maintained any weight loss for up to 1 year at any of these programs?
Yes
No
10. What did you learn from these programs regarding your weight?
11. Why do you think these programs didn’t work?
12. How important is weight loss to you at this time?
Not
Not Very
Somewhat
Very Important
Imperative
13. How does being overweight affect you? Check all that apply.
Limits exercise
Can’t wear my clothes
Tired all the time
My knees hurt
My back hurts
I feel ugly
Others
14. What is hard about managing your weight?
No will power
I’ve always been overweight
No exercise
Schedule too busy
Hungry all the time
I don’t like vegetables
I’m a meat and potatoes person
I’m addicted to sugar
I like beer
Other
15. Do you follow a special diet?
No
Diabetic
Low Sodium
Low Fat
Kosher
Vegetarian
Other
16. Which meals do you eat regularly?
Breakfast
Lunch
Dinner
17. When do you snack?
Morning
Afternoon
Evening
Late Night
Throughout the day
18. What are your favorite snack foods?
19. How is your food usually prepared?
Baked
Broiled
Fried
Poached
Steamed
Other
20. How many items per day do you have the following items?
Starch (bread, cereal, pasta, rice)
Fruit
Vegetables
Dairy (milk, yogurt, cheese)
Meat (fish, poultry, eggs)
Fat (butter, margarine)
Sweets (candy, cake, juice)
21. How many of these items do you have daily?
Water
Coffee
Tea
Soda
Alcohol
Other
22. What habits would you like to change?
23. Is your decision to lose weight your own or for someone else?
Mine
My wife
My husband
My parents
My friends
24. Is your family supportive?
Yes
No
25. What can’t you do now that you would like to do if you weighed less?
Ride a bike
Go bowling
Play golf
Go for walks
Play with my children
Get into my old clothes
26. What would you like to get out of this visit regarding your weight?
A diet
Accountability
Understanding what makes me fat
Medication
Evaluation what making me fat
