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Positive Weight & Wellness Intake Form
Name
*
First
Last
Age
*
Email
*
Why do you want to lose weight?
*
How does your weight limit you?
*
Do you believe you can lose weight?
*
Yes
No
Are you currently trying to lose weight?
*
Yes
No
If yes, in what fashion, or by what means?
*
What steps have you taken in the past to lose weight?
*
Have you struggled with binge eating or emotional bingeing in the past?
*
Yes
No
Do you currently binge eat?
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Yes
No
Do you ever purge?
*
Yes
No
What is your activity level?
*
Sedentary (very little activity daily)
Somewhat active (some walking/ moving my body)
Active (daily activity/ stretching/ walking)
How long have you been overweight?
*
What do you remember about food and eating while growing up?
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What are three things that you'd like to change right now in your life?
*
How do you spend your time during the day?
*
What do you do when you have free time?
*
What are your responsibilities?
*
Would you consider yourself spiritual? (belief in God, the Universe, energy, etc)
*
Yes
No
A little
Are you in a relationship?
*
Yes
No
How would you rate your current happiness in your relationship? (Subject to change daily!)
*
1
2
3
4
5
6
7
8
9
10
Please chose one- '1' being the lowest happiness and '10' being the highest.
How often do you have fun?
*
Every day
A couple times a week
Once a week
A few times a month
Maybe once a month
Do you have best friends?
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Yes
No
'Best friends' is open to your own interpretation.
Do you do any volunteer or community activities?
*
Yes
No
I have
I'm going to soon
Please choose the best option that describes your stress levels.
*
I'm often stressed, I'm often running on adrenaline, breathing shallowly.
I'm emotionally stressed- there's lots going on in my life that feels heavy.
The way I think about my world makes me stressed. I think negatively.
I find time to relax and breathe deeply.
I don't experience a lot of stress unless stressful circumstances present themselves.
I'm pretty easy going, I rarely experience stress.
What gives you stress?
*
Are you working toward any goals right now?
*
How would you like to be living in 5 years from now? Please describe.
*
Please check any conditions that may apply to you.
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Acne
Allergies
Aches and pains
Low blood sugar- shaky and light headed
Mood swings
Constipation
Eczema/Dermatitis
Fatigue
Headaches
Loose stool
Bloating
Depression
Guilt/Shame
Self-criticizing
Compulsive thinking about food
Loneliness
Fear
Diabetes
High blood pressure
High cholesterol
Strong food cravings
Please share anything else you feel to be important about your current lifestyle/ relationship to food.
*
Submit