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Personal Goals & Intake Form for STRIVE FIRST NAME, MIDDLE INITIAL

LAST NAME

DOB

AGE

____/____/____ MARITAL STATUS: M

S

D

W

Current Weight #

DP Other

MM DD YYYY Are you in therapy now?

Height ‘ “

YES

NO

Who referred you to us?______________________________________________ Have you had bariatric surgery?

YES

NO

If YES, which type (circle one): Gastric Bypass Gastric Band Gastric Sleeve OTHER: ________________________________________ Have you had more than one bariatric surgery (revision)?

YES

NO

Who was your surgeon? (check on, or provide name):

Dr. Andrew Averbach

Dr. Kuldeep Singh

Dr. Isam Hamdallah

OTHER:__________________________________________________________________________________________ OCCUPATION

            

How did you hear about us? (for marketing purposes only) □ Support Group Meeting □ Nancy Lum, RD, LDN □ Dawn O'Meally, LCSW-C, P.A. □ Brochure/ Postcard □ Email □ Facebook, Twitter or LinkedIn □ Gym/ Health Club □ Dr. Averbach □ Dr. Singh □ Dr. Hamdallah □ Another Healthcare Professional □ Friend/Co-worker □ Other: ______________________________________________________

Personal Goals & Intake form for STRIVE | STRIVE (rev. 9-4-2012hn)


MEDICAL HISTORY COMORBIDITIES CORONARY ARTERY DISEASE DIABETES TYPE I DIABETESE TYPE II HIGH BLOOD PRESSURE (aka Hypertension or HTN) HIGH CHOLESTEROL SLEEP APNEA

DIGESTIVE/ GI RELATED DISORDERS BARRETT’S ESOPHAGUS

OTHER CONDITIONS ANEMIA/ IRON DEFICIENCY

CELIAC DISEASE CHRONIC CONSTIPATION CROHN’S DISEASE

ANXIETY ARTHRITIS BIPOLAR

DIVERTICULITIS DIVERTICULOSIS IRRITABLE BOWEL (IBS/ IBD) REFLUX DISEASE (GERD) ULCERATIVE COLITIS

DEPRESSION GRAVES DISEASE HASHIMOTO’S DISEASE HYPERTHYROIDISM HYPOTHYROIDISM LACTOSE INTOLERANT OCD OSTEOPENIA OSTEOPOROSIS STROKE VITAMIN D DEFICIENCY

OTHER MEDICAL CONDITIONS (PLEASE LIST):

Vitamins you are currently on (Brand, Dosage, Number per day)

Personal Goals & Intake form for STRIVE | STRIVE (rev. 9-4-2012hn)


Personal Goals for STRIVE: If you had a magic wand and could solve all of your problems, what would be on your wish list? How would your life change? Please list at least three personal goals you would like to accomplish through your participation in the STRIVE program.

1. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

2. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

3. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

MUST BRING COMPLETED TO FIRST CLASS!

Personal Goals & Intake form for STRIVE | STRIVE (rev. 9-4-2012hn)


Personal Goals & Intake Form