Submitted by ahs-admin on Thu, 10/19/2023 - 10:05 You must have JavaScript enabled to use this form. First Name * Last Name * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Height * Current Weight (lbs) * Insurance Provider * Insurance ID Number * What is your current motivation for weight loss? * When did you notice that you struggled with your weight? * Highest Adult Weight (lbs) * Lowest Adult Weight (lbs) * Ideal Adult Weight (lbs) * Rate of weight gain (lbs/year) * Any known factors which would contribute to weight gain (ex. life events, medications)? * Women: if pregnancy contributes, how much weight did you gain after each pregnancy? (lbs) Women: Are you currently on birth control? Yes No N/A Do any family members struggle with weight? If so who? Have you made any previous attempts to lose weight in the past? Diets Self Directed Medically Supervised Prescription medications? If so, what? What worked well in the past? How much weight were you able to lose? (lbs) How long were you able to maintain weight loss? Activity: Current activity level * Have you been more active in the past? * Yes No Activity Type How often? What changed? What activities do you enjoy? * Sleep: How many hours of sleep do you get on average? * What time do you get up? * What time do you go to bed? * Have you previously been tested for sleep apnea? * Yes No Social history: Who lives in the house with you? * Who shops? * Who prepares meals? * Any history of tobacco or nicotine use? * Any history of alcohol use? * Any history of illicit street drugs? (exp. marijuana, meth, cocaine...) * Leave this field blank Submit