Intake form - Individual - JINJERLI Weight Management Practice

Intake form - Individual

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Step 1 of 10 - Personal Information

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Company

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Name*

First Last

Email*

Enter Email Confirm Email

Phone

Pronouns

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Next of kin*

Phone*

Relationship

Informed Consent

The pre-screening and health screening assessment part of this program will include the collection of health and fitness information. Information is sought through this questionnaire as well as measurements. Information gained from this assessment will be used as the basis for an individualised weight management program. Your client information is strictly confidential but may be given to your medical or allied health professional with your consent. Any questions regarding this assessment are welcomed at any time. I have read this form and I understand the assessment procedure and consequent weight management program that I will undertake. I consent to participate in this assessment and weight management program and I withdraw my right to make any claim of any kind whatsoever, against the organisation, and the practitioner that will conduct this assessment and weight management program for any injury, illness or adverse change in my medical condition or state of health arising directly or indirectly from the tests, program or advice I have received from the practitioner, before, during and after the assessment and subsequent weight management program.

Signature*

Date*

Month

Day

Year

GENERAL HEALTH

Please note: Sex assigned at birth may influence aspects of program planning, such as calorie and macronutrient requirements. You have the right to disclose or not disclose this information; however this information can impact the effectiveness of any program produced.

Gender

Date of birth*

Day

Month

Year

Weight*

Goal Weight

Lowest adult weight*

Height*

Medical & Health Conditions

Check any that apply or describe any additional conditions

No conditions

Insulin resistance

High blood pressure

Atherosclerosis

Cardiovascular disease

Stroke

Cancer

Type 2 Diabetes

Gall bladder disease

Polyendocrine Metabolic Ovarian Syndrome
- formerly PCOS

Musculoskeletal problems

Liver disease

Kidney disease

Gout

Cataracts

Stress Incontinence

Sleep apnoea

Pancreatic disease

Other - explain (if no conditions exist, please confirm by selecting no conditions)

Additional information

Have you had any recent surgery? If so, explain.*

Do you currently take medications? If so, what and for what conditions?*

Does your family have a history of any medical conditions? If yes, please list.*

Are you pregnant of breastfeeding?*

APSS - Adult Pre-exercise Screening Survey

AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual. This stage may be self-administered and self-evaluated by the client. Please complete the questions below. Should you have any questions about the screening form please contact your practitioner for clarification.

Has your doctor ever told you that you have a heart condition or high blood pressure?*

Yes

Do you feel pain in your chest at rest, during daily activities, or when you do physical activity?*

Yes

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?*

Yes

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*

Yes

Do you have a bone, joint, or soft tissue problem that could be made worse by physical activity?*

Yes

Has your doctor ever said that you should only do medically supervised physical activity?*

Yes

EXERCISE DURATION AND INTENSITY

On how many days in the past week did you do moderate physical activity (e.g. brisk walking, light cycling) for at least 10 minutes?*

Please enter a number from 0 to 7.

On those days, how many minutes did you usually spend doing moderate activity?*

Please enter a number greater than or equal to 0.

On how many days in the past week did you do vigorous physical activity (e.g. running, fast cycling) for at least 10 minutes?*

Please enter a number from 0 to 7.

On those days, how many minutes did you usually spend doing vigorous activity?*

Total activity minutes weekly

Guidance Total Weekly Activity 150 minutes or more - Meets recommended guidelines Less than 150 minutes - Below recommended levels Total Weekly Activity Interpretation 150 minutes or more Meets recommended guidelines Less than 150 minutes Below recommended levels

EXERCISE HABITS

Weekly Exercise Information Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period.

Include type of activity, duration, intensity and times per week*

How often do you stretch?*

Professional activity*

How would you rate the activity level of your profession, or what you do during the day (non- exercise related)? Circle the option.

Sedentary

Moderately Active

Active

Very active

Which best describes you?*

Sedentary adult

Exercising adult

Growing teenage athlete

Competitive athlete

Athlete restricting calories

Adult building muscle

Which of the following forms of physical activity would you be interested in participating in?*

Walking

Running

Resistance training

HIIT

Group exercise

Swimming

Cycling

Gym

Other:

Other - provide details

Lifestyle Questionnaire

What time do you normally wake up?*

What time do you normally go to bed?*

Rate the quality of your sleep and any relevant details.:*

Do you smoke? If yes how often and for how long have you smoked?*

Do you drink alcohol? If yes how often and how much?*

WHY DO YOU WANT TO LOSE WEIGHT?

This section helps to get a picture of your reasons and motivations for losing weight. Honesty is the way we understand and make progress, so please answer accurately.
You may choose from a scale of 1-5. 1 being not important, 5 being most important.

I want to feel better about myself*

I have a health problem and losing weight could help*

I want praise and approval from others*

I want to wear nicer clothes*

My doctor has advised me to lose weight*

I want to move around more easily*

Someone I care about isn’t happy about my weight*

I want to avoid potential health problems*

I’m concerned about gaining more weight*

I don’t like criticism or judgement from others*

My weight affects how I feel about my attractiveness*

I want to present a better professional image*

My weight may impact my work or opportunities*

Other reason

Weight loss or gain experience:

Select which is most relevant*

I can eat practically anything I want and I don’t gain weight- I find it very hard to gain weight.

I can lose or gain weight by adjusting my activity level and eating habits.

I find it difficult to lose weight. I gain weight easily and have to watch what I eat.

I can lose weight but struggle to keep it off. I generally regain my lost weight after a short time.

Have you ever been placed on a nutrition plan?*

If yes, by whom and what did it consist of?

Yes

Details

Was it successful? what was your experience?

Food Diary

Please list below what you eat and drink on a typical day. Include water, snacks and alcohol. Describe portions according to bowl size.
Food description. Eg 1 medium bowl homemade spaghetti with bought tomato sauce, beef, zucchini, cheese, large glass of wine

Breakfast*

Include time and portion and drinks

Lunch*

Include time and portion and drinks

Dinner*

Include time and portion and drinks

Snacks*

Include time and portion and drinks

GOALS AND BARRIERS

BARRIERS*

Are any of the below applicable barriers to your success in behavioral change?

Time

Money

Poor health

Stress/mental health

Unmotivated

Embarassment/shame emotions

Lack of support

Fear of failure

Life events - eg. menopause

Lack of facilities/equipment

Other

GOALS*

What are your goals?

Weight loss

Improve strength

Improve balance

Improve mental health

Fat loss

Learn exercise technique

Gain weight

Improve eating habits

Improve fitness level

Improve general health

Improve cardiovascular health

Other

SMART Goals

List a SMART short term, medium term and long-term goal. Goals can be weight based, fitness based, health based and mental health.

S= Specific
M=Measurable
A=Achievable
R=Realistic
T=Time based

As a guide, a common sustainable weight loss goal is 500g per week.

Other goals can include body recomposition, fitness, or mental health. If you do not have a specific goal we can discuss this later.

Short - 10 weeks

Medium - 6 months

Long - year

YOUR Story

Please use this space to provide additional information.

Please review and accept the terms and conditions.*

Additional terms of service to review.

I have read the Jinjerli Contract and agree to allow JINJERLI to design a weight management solution for me, to help me achieve my health and wellness goals. I will commit to follow the program to the best of my ability. I understand the inherent risk associated with undertaking a nutrition and exercise program, and I will not hold Jinjerli and/or its employees and contractors personally liable for any problems, illnesses or injuries that might occur due to a sudden change in my eating habits and exercise. This weight management program does not replace the expert advice or medical treatment of my own private doctor. I have answered the Client Profile Questionnaire truthfully and have provided Jinjerli all necessary information about myself to prevent any possible complications.

Signature*

Date*

Month

Day

Year