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Weight Management Intake Form
Step
1
of
17
5%
The following questions will help our Allied Health Team to create a treatment plan, customized for you.
Please make sure to answer the questions as accurately as you are able to.
What are your weight management goals? Choose all that apply.
Improve my quality of life
Improve my health
Improve my confidence
Have more energy
Fit better in my clothes
Prevent weight gain
Address health concerns or risks
Which of the following applies the best to you. Choose all that apply
Caucasian (White)
East Asian
South/Southeast Asian
Hispanic or Latino
Middle Eastern or Arab
Native American
Mixed Ethnicity
Other
Prefer not to answer
Other
Do you have any allergies? ie. Food/Seasonal
Yes
No
List allergies here
Does anyone in your family experience any of the below conditions?
Parathyroid cancer
Thyroid Cancer
Adrenal Tumour/Cancer
Multiple EndocrineNeoplasia Syndrome
Sleep Apnea
Diabetes
High Cholesterol
Other
None of the above
Describe who these pre-existing conditions apply to:
(Required)
Have you experienced any issues with your sleep?
Do you snore loudly?
Yes
No
I DON'T KNOW
Do you often feel tired after waking up or throughout the day
Yes
No
I DON'T KNOW
Has anyone ever said you stopped breathing or choke during your sleep?
Yes
No
I DON'T KNOW
Have you experienced any changes in your mood or outlook?
How often are you feeling gloomy or sad
Never
Rarely
Sometimes
Often
Always
Have you been diagnosed with a mental health condition?
Yes
No
Are you currently taking medication to address a mental health condition?
Yes
No
Do you smoke? This includes all tobacco, cannabis, vapes, and other smoking products.
Yes
Yes but I want to quit
No
Do you drink alcohol?
Yes
Yes but I want to quit
No
Do you currently take any prescription medication, over the counter medications, herbal or vitamin supplements?
Yes
No
Please list the medication or supplements you are currently taking, including strength and dosages if applicable.
Have you been diagnosed with Diabetes?
Yes
No
If Yes, have you also been diagnosed with the following: Select all that apply:
Diabetic Eye Disease (retinopathy)
Diabetic ketoacidosis (ketones in urine or blood)
Diabetic nephropathy (kidney damage)
Cardiovascular conditions
Have you tried weight management treatments before? Choose as many as apply and specify the treatment or change
Yes I've taken medication for weight loss
Yes I've made modifications to my diet
Yes I've incorporated exercise regimes
I have not tried any weight management treatments
I've tried treatments not listed here
Please describe
Have you experienced any drastic changes in weight in the last 6 months? If Yes, what was the change in weight?
Yes
No
Please describe the change in your weight
Please select the diets you have tried. Select all that apply
Mediterranean
DASH
MIND
Mayo Clinic
TLC
Volumetrics
Weight Watchers
Extreme low calorie diet
Intermittent Fasting
Other
None
Other
Please upload an image of your provincial health card and enter the number below if applicable
Health card image
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Health card number
Please upload an image of your private drug insurance card and enter the number below if applicable
Private drug insurance image
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Private drug insurance number
Upload a photo of government issued ID (e.g. drivers license).
Please make sure
Your ID is valid and within the frame
Your information is clearly visible
ID image
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
And you're done! Thank you for your responses. After you submit the intake form, our Allied Health Team will review your responses and our team will reach out for a consult with the Allied Health Team. Please look out for an email from support@3.99.210.59 in the next few days. Thank you for participating in the Get Gambit Weight Management Program and taking that first step towards a happier and healthier you.