PERSONAL HEALTH ASSESSMENT

Motive Weight Loss Center was created to help you improve your health by losing weight. We are not a medical practice or organization, and our staff cannot provide any medical or psychological advice. You are advised to seek professional medical advice prior to initiating our program, especially if you have any pre-existing health conditions or are taking any medications.

First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:
Date of Birth:
Age:
Profession:
Weight:
Height:
Goal Weight:
How did you hear about us?:
EXERCISE AND PERSONAL HABITS:
Do you exercise?: YesNo
If yes, what type::
How many days per week:
Have you attempted to lose weight before?: YesNo
If yes, please specify which diet program and why you think it didn’t work for you:
SLEEP QUALITY: Rate 1-5 (1 Poor - 5 Great):
STRESS: Estimate the % that life stress effects your eating habits:
Work:
Relationships:
Financial:
Health:
Family:
Personal Appearance:
Personal Loss:
Other:
REASONS I WANT TO LOSE WEIGHT: List as many reasons as necessary:
How do you feel about approaching weight loss?
I expect to be uncomfortable during weight loss: NeverMaybeDefinitely
Losing weight is worth the discomfort: NeverMaybeDefinitely
I will succeed: NeverMaybeDefinitely
Controlling my eating is my responsibility: NeverMaybeDefinitely
I can achieve my weight loss goals: NeverMaybeDefinitely
EATING PATTERNS:
Breakfast:
Do you eat breakfast every morning? YesSometimesNever
Approximate time?
What do you typically eat for breakfast?
Snacks:
Do you have a mid-morning snack? YesSometimesNever
Do you have an afternoon snack? YesSometimesNever
Do you have an evening snack? YesSometimesNever
Approximate time(s)?
What to you typically eat for snack?
Lunch:
Do you eat lunch everyday? YesSometimesNever
Approximate time?
What do you typically eat for lunch?
Dinner:
Do you eat dinner everyday? YesSometimesNever
Approximate time?
What do you typically eat for dinner?
Which type of foods do you prefer? SweetsSaltyFatty
How many ounces of water do you drink a day?
How many cups of coffee do you drink a day?
What type of creamer? What type of sugar/sweetener?
Do you drink soda? YesNo
If yes, what type?
Do you drink alcohol? YesNo
If yes, what type and how often?
MEDICAL INFORMATION:
The following key will be used as it relates to certain medical conditions:
NE - Not Eligible; DP – Doctor Permission required; CC – Close Contact with Motive Coach
List your medical physicians and their area of practice:
Diabetes:
Do you have Diabetes? YesNo
If yes, are you under the care of a physician? YesNo
What type of diabetes? Type 1 Insulin Injection Dependent (NE)Type II Non-Insulin Dependent (diabetic pills)Type II Insulin Dependent (diabetic pills and insulin) (CC)
Cardiovascular:
Have you had any of the following conditions? Check all that apply: Blood Clot (NE/DP)Pulmonary Embolism (NE/DP)Coronary Artery Disease (NE/DP)Stroke or TIA (NE/DL)Heart Valve Problem (NE/DP)Heart Valve Replacement (NE/DP)Arrhythmia (DP)
Do you have a pacemaker? (DP/CC) YesNo
Heart Attack YesNo
If yes, what was the date: (NE if within last 6 months)
History of Congestive Heart Failure (DP) YesNo
Have you ever had any type of heart surgery? YesNo
If yes, which type and when?
Are you currently taking high blood pressure medication? YesNo
Are you currently taking cholesterol medication? YesNo
Has your doctor restricted your sodium intake? YesNo
Liver and Kidney Function:
Do you have Liver problems? (DP/CC) YesNo
If yes, specify:
Have you ever been diagnosed with kidney disease? (DP/CC) YesNo
Have you ever had a kidney transplant? (DP) YesNo
Are you taking medications for this condition? YesNo
If yes, specify:
Have you ever had kidney stones? (CC) YesNo
Have you ever had gout? (CC) YesNo
Colon Function: Check all that apply:
Irritable Bowel SyndromeDiverticulitisConstipationUlcerative Colitis (CC)Crohn's Disease (CC)Diarrhea
Digestive Function: Check all that apply:
Acid RefluxGastric Ulcer (DP/CC)HeartburnHistory of Bariatric Surgery (DP/CC)
Endocrine/Glandular Function: Check all that apply:
Thyroid ProblemsParathyroid ProblemsAdrenal Gland Problems
Neurological/Emotional Evaluation: Check all that apply:
Panic AttacksBulimiaAnxietyBipolar DisorderDepressionEpilepsySchizophreniaAlzheimer's DiseaseAnorexia (CC)Parkinson's Disease
List any medications you are taking for these conditions:
Inflammatory Conditions: Check all that apply:
MigrainesLupusPsoriasisFibromyalgiaMultiple SclerosisLyme DiseaseRheumatoid ArthritisChronic Fatigue SyndromeOther AutoimmuneOsteoarthritis
Cancer:
Do you have active cancer? YesNo
If yes, what type and where is it located?
Has your cancer been in remission for more or less than 5 years? MoreLess
Allergies:
Are you gluten intolerant? YesNo
Do you have Celiac's disease? YesNo
Are you allergic to: Peanuts/Tree NutsDairySoy
Any other food allergies?
General:
Do you have any other health problems? YesNo
If yes, specify:
Do you take any other medications? YesNo
If yes, specify:
Do you take vitamins, herb, supplements? YesNo
If yes, specify:

The information above accurately represents my health, medical, and personal history. The information you receive in your consultation and while on the Motive Weight Loss Program is not considered medical advice. Do not change or modify your medical plan without first consulting your physician(s).

Motive Weight Loss Center is designed to change the success of your weight loss journey by providing you with a practical guided approach. Client success is the most important part of what we do.

You will meet with a Motive Coach at least weekly to address the reasons why you have added weight and how to move forward in your improved nutritional health. Our clients have a desire to change, and we want to help them put a stop to their unhealthy eating habits.

Motive Weight Loss is a high protein lifestyle with low carbs, fats, and sugars. We will provide 70% of the foods you will eat each day. This includes breakfast, lunch (with added vegetables and salads), and 3 snacks per day. We will meet with you to plan dinners that will consist of protein and approved vegetables and salads.

The financial investment in your Motive Weight Loss Program is based upon the number of weeks required to reach your Motive Goals. The number of weeks will be determined by your personal body composition results and your health history.

I am motivated to share reasons that have led to weight gain and discuss how Motive Weight Loss will change the direction of my eating habits and my health.

Signature:
Date:
Parental consent required for all clients under the age of 18:
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Date:

Motive Weight Loss Center
6339 Ten Oaks Rd #100
Clarksville, MD 21029
Phone 410-698-9203

Motive Weight Loss Center was created to help you improve your health by losing weight. We are not a medical practice or organization, and our staff cannot provide any medical or psychological advice. You are advised to seek professional (medical) advice prior to initiating our program, especially if you have any health situations and/or are taking any medication. Individual weight loss results may vary.