Patient Name

First

Last

(MI)

Patient Address:

Street

City

Province

Postal Code

Home Phone

Cellular

Birthdate

Sex

M
F
Other

Patient Employer

Patient Occupation

Employer Address

Street

City

Province

Postal Code

Work Phone No.

Ext.

In Case of Emergency

Relationship

Phone

Patient's Spouse *

Phone

Family Physician *

Phone

Referred By

Cancer Type

Other Diseases

Operations: (Dates)

Current Medication (Vitamins, Birth Control Pills) :

Any Mood Altering or Depression Medication:

Allergies to medicines, foods, etc :

Family History

Age

Deceased

Age / Cause

# of Siblings

# Living

# deceased:

Cause

Examination

Reason

Hospitalizations

Dates

Reason

X-Ray: Chest

Stomach

Gallbladder

Kidney

Colon

Other

Date of Last Laboratory tests:

Electrocardiogram (Heart tracing)

Date of last pap (Cancer Smear):

Weight History

When did you first become overweight? (your age then)

Date-Year

How did your weight gain start? Describe any cirsumstances:

What do you think if the cause of your weight problem:

Your Present weight?

Your Goal weight:

Height:

What was your lowest weight?

Your age then:

# of years ago:

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

Have you attempted to lose weight before?

Most weight Lost?

How Long it took:

Describe Previous methods of weight loss (e.g. diets, pills, injections, hypnosis, and acupuncture) and describe your results:

Where and when do you do most of your overeating?

How many meals do you eat a day?

How many times do you snack a day?

How Many times a week do you eat out?

What Foods do you eat when snacking?

How Motivvated are you to lose weight now? (1-none, 10-very motivated)

Do you currently have any Medical concerns? Please list:

Captcha *

Financial Policy:

Thank you for selecting Options Weight Loss Clinic. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. please be advised that payment for all services will be due in advance.

I agreed that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney`s fess and court costs.

I have read and understand all of the above and have agreed to these statements.

All statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. if i willingly withhold knowledge from my treating surgeon and clinical practitioners, I accept fully liability from any consequences arising.

416-962-4444

647-760-3234

416-962-4444

Option Weight Loss Clinic

Patient Intake Form

Information

Plastic Surgery

Procedures

Our Hours