YOUR BEST WEIGHT PROGRAM INITIAL INTAKE FORM

Thank you for choosing the YOUR BEST WEIGHT Program. We admire your courage in embarking on this comprehensive health journey.  

The first step is a consult with a staff doctor. In preparation for that visit, please fill out the intake form below. Thereafter, you will be prompted to book an appointment online.*  

* Important: This form is only for individuals who are not presently a patient at a Pathways to Wholeness clinic. If you are already a patient and need to book an appointment, click here.


Name
Name
Emergency Contact
Name *
Name
Phone *
Phone
General medical
Please list past medical conditions and hospitalizations
Please list medical conditions in the family including: siblings, parents, and grandparents.
Please list all allergies past and present
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
Review of Systems
Please list any other symptoms or health concerns not listed above that you have currently experienced whether they seem related or not to your present chief health concern(s).
Please select usual appearance
Usual appearance of urine Other
Do you get colds, runny noses, and flus easily?
Do you get frequent headaches
Menstruation
How long is your typical cycle?
Description of menstrual flow (color, volume, etc)
Are your cycles regular?
Diet & Nutrition
Diet category *
My typical times for breakfast, lunch, and dinner are? Include snack times
Types of oil I use *
Click all that applies
I use oil for *
Physical Activity & Exercise
How many days a week are you doing structured physical activity?
Please share with us what types of exercise activities you are currently engaged in
Please list any activities you would like to explore and also activities you absolutely dislike doing.
Equipment available at home are
Click all that apply
How do you travel to and from work? *
List if any
Sleep & Sunlight
When do you typically go to bed and when do you usually wake up?
Mood & Emotions
Worry *
Over the last 2 weeks, have you experienced any of the following symptoms?
Mood *
Over the last 2 weeks, have you experienced any of the following problems?
Rate your stress out of 10
1 = No stress 10 = Extremely stressed
Rate your energy out of 10
1 = Absolutely no energy 10 = Full of energy
Miscellaneous
Best method of contact
Please indicate any other comments you feel are necessary for us when considering your case