Intake Forms

Atlanta Weight Loss & Body Balancing offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

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WELCOME TO OUR OFFICE
Today's Date
If this is your first visit to our office, please bear with us in filling out this information sheet. This sheet provides us with information vital to your health and weight loss goals. Be assured that this information will remain strictly confidential. We ask that you attempt to complete each blank as fully as possible.
PATIENT INFORMATION
Name
Birth Date
Age
Male
Female
Social Security #
E-mail Address
Spouse's Employer
Driver's License #
Name of Spouse
Home Address
City
State
Zip
Employer
Home Phone
Occupation
*Mobile Phone
Work Phone
Height
Current Weight
YOUR HEALTH SUMMARY
Stroke
Epilepsy
Headaches
Mood Swings
Heart Attack
Kidney Disease
Neck Pain
Loss of Balance
Diabetes Type 1
Pacemaker
Poor Sleep
Nervousness
Diabetes Type 2
Organ Transplant
Dizziness
Stomach Upset
Thyroid Disease
Cancer
Arthritis
Tension
Gallbladder Disease
Intestine Problems
Mid Back Pain
Cold Feet
Hypoglycemia
Celiac Disease
Lower Back Pain
Gout
Depression
Chron's Disease
Carpal Tunnel Syndrome
Heartburn
High Blood Pressure
High Cholesterol
Fibromyalgia
Fatty Liver
List any medications you are taking and what for
In addition to weight loss, if there was one other health condition or struggle that you would love to see your body heal and/or overcome, what would that be?
Have you been treating by a physician in the last 12 months?
Yes
No
If 'yes', please describe
Are you under regular chiropractic care?
Yes
No
How long have you been overweight?
Have you tried to lose weight in the past?
Yes
No
What are the top 2 reasons you want to lose weight?
Has your doctor recommended that you lose weight?
Yes
No
What is your goal weight?
When was the last time you weighed your goal weight?
On a scale of 1-10, with 10 meaning "I'm serious about losing weight and fully committed", What is your current level of commitment?

Females: Are you pregnant?
Yes
No
Are you on birth control?
Yes
No
Are you breastfeeding?
Yes
No
Do you have an estrogen patch or implant?
Yes
No

C.R.E.A.T.E the New You and Start Today.

2055 Hamilton Creek Parkway #102A
Dacula, GA 30019
(678) 335-4925

The body you want can be yours in three easy steps and 30 days: