personal goals & intake form
DESCRIPTION
Personal Goals & Intake FormTRANSCRIPT
Personal Goals & Intake form for STRIVE | STRIVE (rev. 9-4-2012hn)
Personal Goals & Intake Form for STRIVE
FIRST NAME, MIDDLE INITIAL
LAST NAME DOB ____/____/____ MM DD YYYY
AGE
MARITAL STATUS:
M S D W DP Other
Current Weight #
Height ‘ “
Are you in therapy now?
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
□ 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 DIGESTIVE/ GI RELATED DISORDERS OTHER CONDITIONS CORONARY ARTERY DISEASE
BARRETT’S ESOPHAGUS ANEMIA/ IRON DEFICIENCY
DIABETES TYPE I CELIAC DISEASE ANXIETY
DIABETESE TYPE II CHRONIC CONSTIPATION ARTHRITIS
HIGH BLOOD PRESSURE (aka Hypertension or HTN)
CROHN’S DISEASE BIPOLAR
HIGH CHOLESTEROL DIVERTICULITIS DEPRESSION
SLEEP APNEA DIVERTICULOSIS GRAVES DISEASE
IRRITABLE BOWEL (IBS/ IBD) HASHIMOTO’S DISEASE
REFLUX DISEASE (GERD) HYPERTHYROIDISM
ULCERATIVE COLITIS 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!