Am I a Candidate? Questionnaire

Am I A Candidate? Questionnaire

Thank you for your interest in Scottsdale Healthcare’s Weight Management Programs. This questionnaire will help determine which program best suits your needs, your schedule and your lifestyle. You will be contacted to set up your appointment and help you start creating a healthier you. You may also contact the Weight Management Programs by calling 480-323-4300.

Contact Information

First name
Last name
Home phone
Work phone
E-mail address
Preferred method of contact? Home PhoneWork PhoneE-mail

Your Interest

Are you ready for a lifestyle change? Yes    No

Are you interested in Weight Loss surgery? Yes    No    Don't know

Are you interested in weight loss medications? Yes    No    Don't know

Your History

Do you have known heart disease? Yes    No    Don't know

Have you experienced any chest pain? Yes    No    Don't know

Do you have diabetes? Yes    No    Don't know

Have you ever been diagnosed with hypertension (high blood pressure)? Yes    No    Don't know

Have you ever been diagnosed with hypercholesterolemia (high cholesterol)? Yes    No    Don't know

Do you smoke? Yes    No

Do you exercise 30 or more minutes per day? Yes    No

Do you have is history of anorexia or bulimia? Yes    No

Are you under current care of a physician? Yes    No

Personal Statistics

Please answer the following questions as ethnicity, age and Body Mass Index (BMI) can play a role in your cardiovascular health and treatment.

Race or Ethnicity
Age
Height
Weight
Body mass index (BMI)	(click here for a BMI chart)

I hereby consent to provide information voluntarily to Scottsdale Healthcare regarding this Center of Excellence for Weight Management questionnaire. This information will remain confidential.

I also consent to allow Scottsdale Healthcare to share this information only with other Scottsdale Healthcare clinicians and to use this information to contact me to inform me about the possible educational and treatment options or to tell me about health-related services available to me. Your signature and acceptance is indicated by selecting this option.