Weight Management Intake Form


Adult Weight History

Social Support System

Social History

Do you use tobacco?
Do you use alcohol?
Do you consume caffeine?
Do you use recreational drugs?
Do you routinely exercise?

Medical History

Do you have any of the following? Please select all that apply and provide information for conditions selected under Group A in the area provided below the checkboxes.
Group A (require physician monitoring)
Psychiatric conditions
Are you currently pregnant?

Current Medications

Background pattern

Questions about how AL!VE can help you reach your goals? Get in touch.