fitco Doctor Initial Appointment Intake Form

COMPLETION TIME – 10 MINUTES

Before you proceed to fill out this form please ensure that you have a tape measure and weight scale available so that you can provide the required measurements.

ALL THE FIELDS IN THIS FORM REQUIRE INPUTS – PLEASE ENSURE THAT YOU INSERT AN ANSWER OR NA IN ORDER TO PROCEED

First Name

Last Name

ID Number

Phone Prefix

Mobile Number

Sex

Female Male

Suburb

City

Notes for the Doctor - Comorbidities

Medications

Previous Operations

Allergies

Alcohol Usage (select one)

Not Applicable Low i.e. less than 2 drinks a week Moderate i.e. Less than 10 drinks a week High i.e. More thank 10 drinks a week

Smoking (select one)

Not Applicable Low i.e. less than 2 cigarettes a day Moderate e.g. Less than 10 cigarettes a week High i.e. Less than 70 cigarettes a week Very High i.e. Less than 140 cigarettes a week Extremely High i.e. More than 140 cigarettes a week

Notes for the Doctor - Family History

Pregnancy History (select all that apply)

Contraception

Areas of Stress (select all that apply)

Not Applicable Work Personal Life

Current Exercise (select one)

None Low i.e. 1 to 2 hours a week or less Moderate i.e. 3 to 5 hours a week High i.e. 5 to 10 hours a week Very High i.e. more than 10 hours a week Extremely High i.e. more than 15 hours a week

Joint Pains (select one)

Yes No

Previous Weight Loss Attempts/ Programs Attempted

Breakfast

Lunch

Dinner

Snacks

Hobbies

How long have you been overweight

Current Weight (kgs)

Target Weight (kgs)

Height (centimeters)

Waist Circumference (centimeters)

Hip Circumference (centimeters)

I have read and agree to the fitco Terms & Conditions

I agree

I have read an agree to abide to the fitco Code of Conduct

I agree

fitco Doctor Initial Appointment Intake Form

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