Please note that this form is only for folks coming to the Burlington, VT office. If you have an appointment at our Gilbert, AZ office, the form is here.

Required Field*

**DO NOT DELETE THIS FIELD. IT IS A HIDDEN FIELD THAT ALLOWS FOR EACH SUBJECT OF THE EMAIL SENT TO BE UNIQUE IN YOUR EMAIL INBOX**
Name *
Name
Address *
Address
Phone *
Phone
Referring Person
Address 1
Address 1
Please provide the Address of the Referring Person
Are you an employee or a student at The University of Vermont?
Do you have Medicare as your primary or secondary insurance? *
How do you perceive your weight now?;
How satisfied are you with your current weight?
Date of Birth *
Date of Birth
Have you ever been on a diet?
Please indicate the methods you have used to control your weight in the past *
Are you a member of a sports team, club sport or a fitness center?
Type of activity/exercise, # of times per week, # of minutes per session
(Please indicate typical intake on a "good day" and a "bad day" if they differ) Example: - 3/4 Cup Kashi GoLean Cereal - 3/4 Cup 2% Milk - 1/2 Cup Strawberries - 1 Cup Coffee w/ 1/4 Cup Half-Half
Have you ever had any of the following problems?
Please Check
Has anyone else in your family had any of the following problems?
I eat sweets & carbohydrates without feeling nervous *
I think about dieting
I feel extremely guilty after overeating
I am terrified of gaining weight
I am preoccupied with a desire to be thinner
I exaggerate or magnify the importance of my weight
If I gain a pound, I worry that I will keep gaining
I eat when I am
It usually takes me this long to eat breakfast *
It usually takes me this long to eat lunch *
It usually takes me this long to eat dinner *
It usually takes me this long to eat snack
I spend % of the day thinking about food *