Hope Family Health, NP PLLC

Available Forms

**NEW PATIENT** INQUIRY FORM! (DO THIS FORM 1ST) **NEW PATIENTS: Review of Systems HEALTH COACHING: TLS Questionnaire (Initial TLS Visit) Pre-Visit Form (Established Patients)

HEALTH COACHING: TLS Questionnaire (Initial TLS Visit)

THIS FORM IS FOR PATIENTS ENROLLED IN THE NUTRITION & WEIGHT MANAGEMENT PROGRAM TSL Questionnaire: Please complete prior to your first health coaching visit or class and submit. Thank you.

Today's Date *

Contact Information

First Name *

Last Name *

Date of Birth *

Preferred Phone Number *

Do you give permission for a message to be left at your preferred number? *

Yes, please leave a message on my voice mail

Yes, but only to request a call back

Who can a message be left with? *

Please specify the name of the person, in the event they answer your phone. If you prefer that no one take a message, please indicate "Nobody." If nobody has access to your phone, please specify "N/A."

Email Address *

If you do not have email, please specify "N/A."

Can a message be sent to your email? *

Yes, I understand it is not secure, but give permission

No, please send all information, including reminders and handouts to the secure patient portal

I do not have email

Weight Loss Goals

1. What are your weight loss goals? *

Lose 5-15 pounds

Lose 16-30 pounds

Lose 51-100 pounds

Lose 101+ pounds

I just want to be healthy

2. When do you want to reach your goal weight? *

2 weeks

4 weeks

12 weeks

6 months

1 year

3. What is your commitment level to losing weight? *

I'm extremely motivated; I'll do whatever it takes

High

Average

Low

I need constant encouragement

Dining Out

1. Do you cook or prepare meals each day of the week? *

Yes

2. Do you eat out often? *

I eat out for every meal, including weekends

I eat out for every meal during the work week

I eat out on occasion

I rarely eat out

Behavior and Metabolism

1a. Once you start eating, do you find it difficult to stop? *

Yes

1b. Do you crave breads, pastas, baked goods, chips and other carbs? *

Yes

1c. When you eat carbs (even quality grains), do you feel tired, sluggish or bloated around the waist? *

Yes

1d. Do you consume more than three alcoholic beverages a week? *

Yes

2a. Are you stressed? *

Yes

2b. Have you ever dieted or tried to eat healthier to lose weight? *

Yes

2c. Are you concerned about having a sluggish thyroid? *

Yes

2d. Do you have a problem falling and/or staying asleep at night? *

Yes

3a. Do you eat at least 20-25 grams of fiber daily? *

Yes

3b. Do you skip meals? *

Yes

3c. At every meal, including snacks, do you consume protein? *

Yes

4a. Do you feel tired most of the time? *

Yes

4b. Do you feel that you are stuck in a plateau? *

Yes

4c. Do you feel your metabolism needs a boost? *

Yes

5a. Do you have excess fat? *

Yes

5b. Do you want help increasing lean muscle mass to boost your metabolism? *

Yes

5c. Do you feel that your fat storage problem areas are your hips, butt or thighs? *

Yes

6. Do you currently take a daily multivitamin supplement? *

Yes

7. Do you eat 8-12 cups of fresh vegetables every day? *

Yes

8. Are you allergic to peanuts?

Yes

9. Are you allergic to soy? *

Yes

10a. Have you been diagnosed with HYPERthyroidism (over active thyroid)? *

Yes

10b. Are you sensitive to caffeine or stimulants? *

Yes

Health Conditions

1. Which conditions do you have currently or have had in the past? *

Please mark all that apply

2. What medications are you currently on? *

Please specify the names of the medications you are on. If you do not take any medications, please specify "N/A."

3. What supplements are you currently on? *

Please specify the names of the supplements you are on. If you do not take any supplements, please specify "N/A."

Support and Comments

1a. Do you have any friends or family to support you with your goals to improve your health? *

Yes

If you feel someone is an obstacle to you reaching your goals and is not supportive, please do not list them, even if they are aware of your desire to improve your health.

1b. Who do you consider to be a support person or support system? *

Please specify the name of the person and their relationship to you. If you do not have a support person or support system, please specify "N/A."

2. Please mention any additional comments here:

* Required field