The Healthy Way - Internet Services Sign-Up Form

INTERNET SERVICES PROGRAM
First & Last Name:
Street Address:
City/State/Zip:
Work Phone:	Home Phone:
Fax Number:
Email Address:
Occupation:
Referred by:
Doctor's Name:
Date of Birth:
When did you begin to gain excess weight? What factors do you feel have contributed to your weight gain? What other methods of losing weight have you tried? Please specify: When were you most satisfied with your weight? Why is it important for you to lose weight now? What foods or situations do you find problematic? Do you have a support system that will aid you in your weight loss? What is your current form of exercise? Are you willing to follow through with a maintenance program?

HEALTH HISTORY

Are you pregnant?

Are you a nursing mother?

*Do you have diabetes mellitus?

Diet controlled?

Oral medication?

Insulin shots?

Are you hypoglycemic?

*Have you had cancer?

Are you being treated now?

*Do you have renal disease/insufficiency?

*Have you had kidney stones?

*Do you have anorexia or bulimia?

*Have you had gall stones?

Have you had any specialized surgery?

Please explain:

Do you have any food allergies?

*Are you 50 pounds or more overweight?

Do you have any other medical problems for which you are receiving treatment?

Has your physician recommended that you lose weight?

*Do you presently have high blood pressure (hypertension)?

*Do you take hypertensive medication?

Please list any medications you are taking at this time:

Do you have any gastrointestinal problems or constipation?

*Do you have heart disease?

Do you have a history of headaches?

Do you have any other health concerns?

Choose your Activity Level (amount of exercise minutes/week):
• 45 mins or less/wk Sedentary
• 45 to 120 mins Light
• 120 to 240 mins Moderate
• 240 mins or more Heavy

Height: Weight: Age:

Wrist Measurement:

Sex:

*With a Doctor's prescription, the Healthy Way Program is tax deductible. Contact your physician.

I have answered the above information to the best of my knowledge.

Signature: Date:

Please continue by completing the Nutritional-Metabolic Evaluation on the next page, print them out, sign and date, and mail or fax to The Healthy Way, 3251 Mission Drive, Santa Cruz, CA 95065 Fax: 831-462-2129.

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The Healthy Way • (831) 462-5900

INTERNET SERVICES PROGRAM