tampa children’s ent test intake form Tampa Children's ENT - TEST INTAKE FORM Weight Loss Questionnaire Name * Name First First Last Last Email * Phone 3. Your level of interest in losing weight is: * 1 2 3 4 5 Not interested --> Very interested 4. Are you ready for lifestyle changes to be a part of your weight control program? * 1 2 3 4 5 Not ready --> Very Ready 5. How much support can your family provide? * 1 2 3 4 5 No support --> Much support 6. How much support can your friends provide? * 1 2 3 4 5 No support --> Much support 9a. What has been your LOWEST weight as an adult? 200 lbs. 9b. What has been your HIGHEST weight as an adult? 200 lbs. Medical History: Osteoporosis Heart disease Diabetes Cancer Depression Stroke Parkinson's disease Alcoholism Anemia Arthritis Anorexia Multiple sclerosis Migraine headaches Rheumatoid arthritis Thyroid problems Asthma Appendicitis Bleeding disorders Breast lump Bronchitis Bulimia Chemical dependency Emphysema epilepsy Fractures Hepatitis Hernia Herniated disc High cholesterol Kidney disease Liver disease Miscarriage Pacemaker AIDS/HIV Pinched nerve Pneumonia Polio Prostate problems Psychiatric care Suicide attempt Tumor Ulcers Vaginal infection Venereal disease Whiplash Previous chiropractic care Herniated Low back pain Neck pain Shoulder pain Wrist pain Elbow pain Knee pain Hip pain Ankle pain Fibromyalgia Multiple sclerosis Balance issues Vertigo Anxiety Sinusitis Allergies Headaches TMJ Activities of Daily Living: (what activities cause difficulty or pain?) Sleeping Yard work Walking short distances Repetitive motions Bending for long periods Almost any movement Changing positions Lifting Extended computer use Pulling Walking Pushing Sitting Carrying Driving Getting out of bed Reaching Climbing stairs Twisting Turning Bending Kneeling Squatting Running Coughing and sneezing Working Gardening Cleaning Getting out of bed Putting on socks Overhead lifting Lifting kids Lifting more than 40 lbs. Getting comfortable Lying down Sitting If you are human, leave this field blank. Submit
