Want to Lose Weight? - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Anthropometrics

What is your weight (kg)?

What is your height (cm)?

What is your waist circumference (cm)?

Reason for wanting to lose weight

To improve overall health

To manage a medical condition (e.g. high blood pressure)

To improve physical appearance

To meet a specific fitness goal

Recommended by a healthcare professional

What have you tried so far?

Certain diet (low-carb, intermittent fasting, keto etc.)

Reducing daily calorie intake

Increase physical activity

Medications

Weight loss program

Previous bariatric surgery

What are your challenges to losing weight?

Lack of motivation

Difficulty adhering to a diet or exercise plan

Emotional eating

Weight plateau despite efforts

Cravings

Side effects from medications causing weight gain

Do you have a good support network?

Family

Friends

Guidance from healthcare professional

Difficulty finding support

Medical Background

Please list all your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.)

Please list any medications you are currently taking.

Medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please upload any additional information.

Browse

Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

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